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ESSAY 287 - THIRD DEGREE TEAR

ESSAY 287 - THIRD DEGREE TEAR Posted by PAUL A.
You are asked to review a healthy 35 year old woman 30 minutes after spontaneous vaginal delivery because she is suspected of having a third degree tear. (a) Justify your initial assessment [5 marks]. (b) Which information would you give her in order to obtain informed consent for repair of the third degree tear?[6 marks]. (c) She has a 3C third degree tear. Logically outline your intra-operative interventions to ensure optimum outcome. [9 marks].
Posted by S D.
a) The delivery notes should be reviewed to look for any risk factors for third degree tear such as big baby >4.5 kg, induction of labour or persistent occipito posterior position delivery. Consent for examination should be obtained. Adequate analgesia should be ensured before the examination. Systematic examination including per vaginal and per rectal should be done to assess the degree and extent of injury. The findings should be explained to the woman.
b) The nature of procedure and purpose; Benefits of procedure should be explained. Serious risks such as flatus and fecal incontinence, wound infection and dehiscence needing secondary repair and anovaginal fistulae should be explained. Frequent risks include pain and bruising. Alternative treatments which in this case is none should be explained. It would be done in theatre under regional or general anaesthetic and should be seen by anaesthetist before shifting to theatre. Information leaflets should be given and any questions that the patient may have must be answered honestly.
c) Thorough systematic examination should be done by PV and PR examinations to assess the extent of injury under anaesthetic as the anal sphincter is relaxed under anesthetic. Appropriate identification of structures is crucial for proper anatomical repair and sucessful outcome. Strict asepsis should be maintained and IV broad spectrum antibiotics according to unit protocol should be given to prevent wound infection. Adequate light and use of assistants for proper repair is essential. The person performing the procedure should be competent in the procedure as inexperienced attempts at repair is associated with adverse outcome. Internal anal sphincter should be repaired by interrupted stitches using PDS 3-0; External anal sphincter can be repaired by either end to end or overlapping method as either has been shown to be associated with similar outcome. This should be done by PDS 3-0 or Vicryl 2-0. After repair, a thorough PV and PR examination should be performed to check the integrity of repair and to rule out inadvertent placement of suture in the rectal mucosa. Swabs, needles and instruments should be accounted for and accurate documentation is vital.
Posted by Sowmithya B.
A. Detailed history including the induction of labour, use of epidural analgesia, duration of second stage of labour, malpositions, birth weight of the baby, any difficulty experience in delivering the shoulders, episiotomy(especially midline) should be enquired. Even though all these factors increase the incidence of third degree perineal tears but none of them is a good predictor.
Clinical examination includes vital signs and assessment of amount of blood lost. The perineum should be carefully assessed for the presence of tear and its severity if present. The anal sphincter should be assessed for any discontinuity and the apex of the vaginal tear should be assessed. Per rectal examination should be done to rule out any button hole tear in the anal epithelium. The fitness for anaesthesia should be ascertained.

B. Women should be explained about the injury sustained to the anal sphincter during child birth. These injuries are often not predictable and also not preventable. 9 out of 100 women undergoing vaginal delivery are likely to suffer from this. The repair of the perineum is needed to prevent development of flatus and faecal incontinence. Repair done under analgesia or anaesthesia will improve the outcome. Repair is successful in 60-70% of the patients. Intra operative complications include anaesthetic complication and haemorrhage. The short term complications like perineal pain, suture migration and infection. Long term complications include faecal urgency, faecal incontinence, flatus incontinence, fear of commencing sexual relationship. When properly repaired it will not have any impact on future child birth. The repair will not interfere with her breastfeeding. Informed consent should be taken.

C. Procedure should be carried out in operation theatre for the advantage of strict asepsis, good lighting, appropriate instruments, and necessary assistance. Performing under regional analgesia or general anaesthesia would relax the sphincter torn ends and hence retrieval and approximation without tension can be done. Broad spectrum antibiotic along with metronidazole for anaerobic coverage should be given to combat infection due to faecal contamination. Infection increases wound disruption and fistula formation. The procedure should be done by appropriately trained person or trainee under supervision. Careful examination under anaesthesia should be done to confirm the findings. The internal anal sphincter should be approximated by interrupted suturing using polydiaxanone 000 or poly glactin 00. The external anal sphincter should be approximated either by end to end or by overlapping technique using polydiaxanone 000 or poly glactin 00. Both have similar outcome. The perineal muscles are approximated after suturing the vaginal mucosa by continuous unlocking sutures to avoid foreshortening of vagina. The perineal skin should be sutured .After the surgery vaginal tampons should be removed. Swabs and sharp instruments counts has to be checked. Per rectal examination should be done to ascertain the adequacy of the procedure. Meticulous haemostasis should be achieved as haematomas will cause wound disruption and infection.
Posted by Mark D.

=======================================
Markd.

a)
I will ask history from the midwife for any risk factors that may have caused the tear like prolong labour, instrumental delivery,big baby or shoulder dystocia.these factors may also cause traumatic PPH.i will ask the mother about how she is feeling and asses her emotional and psycological state,I will ask if she has seen and touched the baby.I will assess general wellbeing by checking pulse ,BP,respiratory rate,tempearature,hydration,to confirm hemodynamic stability. I will assess her pain relief.If she is in pain she will need epidural top up dose. I will do a per abdomen examination to confirm well contracted uterus. I will inspect the vulva for any active vaginal bleeding,I will gently asses the tear in lithotomy position by vaginal and rectal examination to confirm that there is third degree tear.I will inform her the findings.There is no proven benefit by endoanal ultrasound to diagnose the degree of tear in immediate post partum period.

b)
I will tell her that she has had a perineal tear during labour which involves her anal sphincter. It needs assesment and repair in the operating room under adequate analgsia and relaxation by person with formal training in perineal tear reapairs. If it is left unrepaired she willl have long term anal incontinence and affect her quality of life. The repair has good success rate and 75%of women are asymptomatic at 1 year of follow up.Repair will be done with delayed absorbable suture materials which will be absorbed by 6-12 weeks.However there is a risk of knot migration.
After repair we will put a catheter to drain urine for 24 hours till her pain settles and she is fully ambulant.
She will need to take laxatives and stool softners for 10 days post operatively to prevent hard stool from disrupting the repair. She will be given adequate pain killers.
She will be asked to follow up at 6 weeks, 3 months, 6 months and 1 year at the dedicated perineal clinic to check for any incontinence.She will be given pelvic floor exercises at 6 to 12 weeks and this will strengthen her pelvic floor and perineal muscles. She should use a reliable contraception to aviod pregnancy till then.She should report if she suffers from stool or flatus incontinence. I will proved her with written information. Plan for subsequent deliveries will be discussed at the time of discharge.

c)
Under adequate relaxation after proper painting and draping and emptying the bladder,I will check for the retracted ends of external anal sphincter and try to identify the internal anal sphincter fibres. I wll retrive the ends of sphinctor.I will approxiamte them end to end with interupted 2-3 stitches with 2-0 vicryl or PDS. Overlapping techinque has similar outcome to end to end approximation. Vicryl and PDS can be used with equivalent outcome. I will separately suture the internal anal sphincter fibres. I will bury the knots under superficial perineal mucles to prevent knot migration. I will suture perineal muscles and vaginal mucosa with continous sutures and approximate skin with 2-0 subcuticular vicryl rapide.This will minimise the perineal pain.I will do a PR examination to check integrity of the repair.I will insert a foleys catheter for bladder drainage and insert a diclofenac suppository perectally for post of pain relief.
I will check the sponge mop instrument count.
Prophylactic antibiotic augmentin and metronidazole will be given at the start of repair because the consequences of infection and wound dehiscence are grave.
Posted by clarice M.
a) I would obtain a history to assess her risk factors for a 3rd degree tear. This includes a history of a previous 3rd or 4th degree tear, use of epidural analgesia and fetal macrosomia. If there is a history of malposition (such as occipito-posterior)or compound presentation, this increases her risk. A midline episiotomy also increases the risk of a 3rd or 4th degree tear. I would ask if the placenta has been delivered as this might affect the ease at which an examination of her perineum can be performed.

I would ensure that the patient has adequate analgesia and that there is good lighting before conducting the examination. These will aid visualisation of the structures damaged.

A vaginal examination will reveal the depth of the tear both cranially and inferiorly. A par rectal examination will enable an assessment of the integrity of the rectal mucosa and anal sphincter. If there is any doubt about the extent of sphincter involvement, advice from a senior obstetrician and gynaecologist will be obtained. If this is unavailable, an assessment in theatre will be made as there is better lighting.

I would site an intravenous cannula as antibiotics will be required if there is a 3rd or 4th degree tear. Blood will also be obtained for a full blood count and group and save as perineal trauma can cause postpartum haemorrhage

b) The extent of the tear will be explained. The nature of the repair will be explained. It will be conducted under regional or general anaesthesia.

The benefits of primary repair of a 3rd degree tear are reduced risk of bowel symptoms such as incontinence of flatus or faeces and urgency. The risks of the procedure are a wound infection, knot migration, haematoma, dyspraeunia, or an inadequate repair leading to bowel symptoms. There is also a small risk of venous thromoboembolism.

Antibiotics and stool softeners will be prescribed to reduce her risk of infection and wound breakdown through straining. Discharge from hospital will depend on how soon she defaecates following the procedure. Physiotherapy will be commenced whilst she is an inpatient and pelvic floor exercises should be maintained.

The alternative to a primary repair is to allow wound healing by secondary intention. The benefit of this is an avoidance of the risks of surgery. The disadvantages are a high risk of bowel symptoms and poor cosmetic effect. Wound healing by secondary intention may take up to 12 weeks and as a consequence, may become infected. An effective primary repair is less likely to result in bowel symptoms compared to a delayed or secondary repair.

c) All swabs, instruments and sutures will be counted at the start of the procedure to avoid accidental retention in the patient.

Broad-spectrum antibiotics and antibiotics to cover anaerobes will be given intravenously to minimise bacteraemia and therefore reduce the risk infection. Good technique is required and supervision of the procedure by a senior obstetrician and gynaecologist should be requested if there is uncertainty regarding the repair.

The ends of the internal anal sphincter should be identified and repaired separately to the external anal sphincter (EAS). It should be repaired with a fine stitch to avoid knot migration towards the rectum or superficially towards the skin. A delayed absorbable suture such as polygalactin will allow adequate healing and reduce the risk of migration.

An overlapping repair of the EAS should be performed as this is less likely to result in urgency of defaecation compared to an end to end repair. Repair of the EAS performed with a braided delayed absorbable suture such as polygalactin is less likely to result in knot migration and irritation compared with polydiaxanone. The knots should be trimmed to avoid knot migration. A rectal examination should be performed to check the integrity of the repair before commencing with repair of the vaginal walls and perineum. This will also ensure that no stitches have been place in the rectum as this can cause a fistula.

A non-locking repair of the vaginal walls commencing from the apex of the tear should be performed with a rapidly absorbed suture. A non-locking repair is less likely to cause dyspraeunia and does not shorten the vaginal length. Failure to secure the apex could result in a haematoma or bleeding.

A continuous repair of the perineal muscle should then be performed followed by subcuticular stitches to the skin. Subcuticular stitches are associated with better cosmesis, healing and less pain compared with interrupted stitches. A vaginal examination should be performed to ensure that all tears have been sutured.

A rectal examination should be performed again to ensure that no stitches have been placed in the rectum as this could result in a fistula.

All sutures, swabs and instruments should be counted again to ensure that none have been left within the patient.

Stool softeners should be prescribed to prevent straining and wound dehiscence. Oral broad spectrum antibiotics and antibiotics that cover anaerobes should be prescribed for 1 week to reduce the risk of infection and wound breakdown.

Thromboprophylaxis should be considered if the patient has other risk factors such as smoking and a BMI greater than 35.



Posted by H H.
TSH
A third degree tear is one that ivolves the skin,vaginal wall ,perinea muscle and anal sphincter and initial assessment and detection is important to allow early repair and avoid morbidity.
I would ask about the situation around the delivery, wether there was fetal macrosomia, delivery in occipito posterior position, wether operative vaginal delivery was conducted , wether there was shoulder dystocia and how managed . I ask if an episiotomy done as midline ones may extend. I would ask wether in her obstetric history if she had a previous tear and was it repaired and if was continent after. On examining her I would see the extent of the tear and wether the external sphincer(IIIA <50% torn IIIB > 50% torn) was torn and wether this was associated with internal sphincter (III C tear).I would look for other tears and do a rectal examination to see if anal wall is intact. However proper assessment of the degree can only be done after giving regional or general anesthesia.


B) I would explain to the patient the situation and that the sphincter that control her stools was torn during delivery and need to be repaired to avoid developing problems with continence. I will tell her that repair will need to be done under regional or general anesthesia and in the operating theater by an experienced person and that she will need to have antibiotics to guard against infection as the area is near the anus. Will tell her that she will be fitted with a urinary catheter after the procedure as she will be at risk of urinary retention and that she will be given laxatives for two weeks to loosen stools to prevent injury to wound by hard stools. Will tell her she will feel some pain after operation and will be given pain killers. I will supply her with written information and even draw to her what will be done before consenting her.



C) Procedure should be done by consultant or under his supervision , in the operating theater under good light and proper antiseptic preparations. She is given intravenous antibiotics . She is given regional or general anesthesia to aid in relaxing the anal sphincter so as to identify the retracted torn ends . The area is explored under anesthesia and extent of tears identified The internal sphincter is sutured with delayed absorbable interrupted sutures. The ext sphincter edges sutured either end to end or overlaping with delayed absorbable suture ,both methods giving same results in healing . The vaginal wall and perineal muscles are sutured with continuos delayed absorbable suture and skin with subcuticular or interrupted suture vicryl rapid. Proper hemostasis and swab count are done. At the end patient fitted with Foleys catheter
Posted by dr neelangini G.
a)History of place of delivery such as whether delivery occurred while conveyance or in toilet, attended by skilled staff/midwife or unattended , as in unattended deliveries because of lack of perineal support more tears will be expected. I would also enquire about the parity of patient as in primipara because of tough perineal muscles extension of episiotomy is more possibility. Previous history of any perineal surgery in the patient which will make her more vulnerable for trauma of labour . weight of the baby is more important to know because macrosomic baby cause extension of episiotomy or tears. Time of onset of active labour & time of delivery is to be taken in account as precipitate labour is associated with more extensive tears . If labour was prolonged possibility of abnormal presentation may be a possibility. Patient’s ethnicity is also important as in some African patients because of female circumcision there will be scarring of vulva causing more damage & tears. In women of asian origin , distance between introitus & anus is small, causing more extension of episiotomy esp, midline episiotomy as well as tear. I would also enquire about type of episiotomy if given , as midline episiotomy is more associated with third degree perineal tears. On examination , general condition of the patient to be assessed quickly to rule out hypotension, tachycardia, cold clammy skin, severe pallor as these findings may suggest severe blood loss associated with the tear – PPH. Per abdominal examination to rule out uterine atonicity . With her consent , I will do per vaginal examination in lithotomy position under good light & adequate analgesia to confirm the degree of tear. I would like to do PR examination to rule out rectal injury.
B) Sympathetic approach in explaining situation is essential . I will inform her , preferably in presence of her partner that while delivering her baby, injury has occurred involving her vagina & extended upto the end of excretory passage. I will inform that vaginal tears are common during delivery. Likely cause in her case should be explained . I will tell her she requires a surgical procedure which will be better taken in operation theatre . She will require anaesthesia / analgesia. She may require blood transfusion if associate with PPH . I will explain her the procedure & its complications like infection, dysparunia,wound dehiscence, faecal incontinence or fistula formation. I will also tell that during postoperative period she may require laxatives to avoid hard stools.

c) After stabilizing her general conditions & with informed consent ,I will post her for repair of tear as soon as possible,as delayed surgery may increases the chance of infection.I will do it in operation theatre,under good light & good exposure,for which I will put her in lithotomy position. Procedure to be done by appropriately trained person or trainee under supervision. Under adequate anesthsia & with all aseptic measures,I will start with the repairing of anal sphincter,with an absorbable synthetic suture like Vicryl 3-0,with intermittent stitches.Once sphincter is sutured ,I will suture the vaginal mucosa,& muscle in layers with Vicryl no 2-0 ,continuous non interlocking suture . Skin will be repaired by same suture material with a subcuticular stitch.After the procedure,I will do PR examination,to rule out any extension of the stitches involving rectum & will insert analgesic pessary to reduce postoperative pain.
Posted by Neelam A.
I would like to know delivery details and previous obstetric history to find out risk factors for third degree tear. Previous third degree tear, primipara, big baby, delivery complicated shoulder dystocia, head delivery as occipitoposterior and midline episiotomy are associated with a higher risk of third degree tear. Presence of these factors would favour this diagnosis although it would not change the management
A proper vaginal and rectal examination in lithotomy position in presence of good light and adequate analgesia should be performed to assess the degree and severity of perineal trauma. If no analgesia is on-board, she should be transferred to theatre for examination under anaesthesia (EUA) and repair of the tear. It always better to over-estimate the type of tear rather than under-estimate.
She should be informed about the diagnosis and its implications. The name of the operation and what it involves should be discussed. Benefits of doing operation and the serious and frequently occurring risks should also be discussed and documented in her notes. If she declines the surgery, she should be informed about its consequences in form of incontinence for faeces and flatus. She should also be informed about any additional procedure needed per-operative such as repair of rectal mucosa or colostomy and need to involve colorectal surgeon. She should also understand that despite good surgery there is a possibility that she might continue to have symptoms of incontinence. Her wishes should be taken in consideration. An information leaflet should be provided.
It should be sutured in theatre in good light and in adequate analgesia by experienced doctor or under supervision. EUA including rectal examination should be done. Internal sphincter should be sutured with PDS and interrupted sutures. External sphincter can be sutured with PDS (delayed absorbable material) as well either by overlapping technique or end to end anastomosis. Recently few studies showed better outcome following overlapping method than end to end anastomosis. Knots should be buried under muscle layer. Vaginal mucosa and muscle layers should be sutured by continuous stitches with vicryl rapide. Subcuticular skin stitches would reduce amount of pain after this surgery. Intra-operative IV antibiotics should be given and oral antibiotics should be continued next 10 days along with analgesia and stool softnors. Foley catheter should be left for few hours after regional analgesia. Rectal examination should be done to check the integrity of rectal mucosa and rectal suppository can be given at the same time. Swabs, sharps and instruments count should be done after the procedure. Documentation should be done. Incidence from should be filled. She should be referred to physiotherpy for pelvic floor excercise. A follow up appointment should be made with consultant in 6-8 weeks.
Posted by Dr Dyslexia V.
X

a. I will assess her by taking a quick history in regards to age, parity, comorbidity for anesthetic risk such as underlying heart disease, hypertension anemia or diabetes which could predispose to infection. The risk factor for the tear also illicited, such as instrumental delivery, macrosomic baby, dystocia, OP position or type of episiotomy performed to facilitate my counselling later on. Her vital signs are taken to aseses her hemodynamic status and the amount of blood loss estimated for any resuscitation required. I would deliver the placenta if the third stage was incomplete to facilitate my vaginal assessment. I would put her in a lithotomy position to facilitate my vaginal asessment and the intergrity if the anal tone assessed via a per rectal examination.


b. I would inform her that she sustained an injury from the vagina to the anal sphincter which could occur in about 1 in 100 vaginal deliveries. Primary repair done properly could make her better in 60 to 80% of the time. I would explain that secondary repair of the tear carries a worse outcome and should be done promptly for optimum results. The anesthetic risk is minimal and at is essential a good assessment and repair. In spite adequate repair there is still possibility of flatus or fecal incontinence. There is also risk of rectovaginal fistula occurring but it is rare. Antibiotics wil bee given for prevention of infection and might be required pot operatively. Laxatives also will be given post operatively for anastomotic intergrity. Blood transfusion may be required if there was excessive bleeding during procedure . Option of a caesarean section will be given for future pregnancy. A formal followup will be done and if required a referral to colorectal surgeon .

c. The procedure should be done by a obstetrician with a adequate training in the management of third and fourth degree tear. It should be done under regional or general anesthesia for thorough assessment , proper identification of the perineal anatomy and repair. It should be done in the operating theater with adequate lighting and assistant. The procedure should be done under aseptic technique with antibiotic coverage preferably such as cefuroxime with metronidazole. Proper speculum used for viewing. PDS sutures or polyglactin sutures uses such as vicryl 2/0 for repair. The internal sphincter should be sutured end to end with interrupted sutures while the external sphincter could be done either end to end or overlapping interrupted sutures. Burying of the knots is recommended as it prevents knot migration. After suturing the mucosa and skin a per rectal examination done to confirm no penetration of sutures to the anal mucosa have taken place as it could result in a fistula.
Posted by Farzana N.
a) Initial assessment of the patient would include taking a quick history from the midwife about the weight of the baby and course of labor. Macrosomic baby (>4.5kg) and dysfunctional labor is associated with perineal tears.Equire about the type of episiotomy given,midline episiotomy is associated with extension and tears.
Patient should be examined to assess the amount of blood loss and need for resuscitation.
General examination should include P,BP,T and respiratory rate.Tachycardia and low BP indicate the need for resuscitation.Two large bore canulae are inserted and iv fluids started.Blood is grouped and crossmatched,clotting profile and U&E done
Vaginal and rectal examination done to ascertain the extent of perineal injury and any other associated vaginal or cervical laceration should be noted.Accurate assessment of extent of perineal injury is very important medicolegally and for adequate repair.
b) Nature of injury should be explained to her.She should be told that it is one of the complications of vaginal delivery which can happen in 0.5-1% cases.It requires repair,which would be performed under anesthesia as per RCOG recommendations.Prognosis is excellent after adequate repair.If left untreated she may end up with complications such as high risk of infection fistulas,urinary and anal incontinence,and sexual dysfunction. Postoperatively.she would be given adequate analgesia for pain relief,and laxatives to soften her stools.She would be followed up by colorectal surgeon ,who would assess her condition postnatally and advise regarding her future pregnancy and deliveries.Written information is given and consent obtained .Clear documentation of all the information given and intended procedure is very important.
c)It is recommended by RCOG that the repair should be conducted by an appropriately trained practitioner or trainee under supervision,as inexperienced attempts at anal shincter repair may contribute to maternal morbidity especially anal incontinence.This should be done in operating theatre ,under general or regional anesthesia.This allows repair to be performed under aseptic conditions with appropriate instruments, adequate light and an assistant.
EAS can be repaired with PDS or Vicryl with equivalent outcome.
Repair of IAS is performed with fine suture size i.e 3-0 PDS or 2-0 Vicryl .This causes less irritation and discomfort.Repair of EAS by overlappindg or end-to-end approximation can give equivalent outcome.IAS may be repaired separately with interrupted sutures. During the repair of anal sphincters surgical knots should be buried beneath the perineal muscle to prevent knot migration to skin. Long acting and non absorbable sutures are associated with possibility of knot migration to the suface.
Vaginal mucosa is sutured with locking stitches. Perineal muscles are sutured with interrupted 2-0 polygalactan stitch.
Skin sutured with subcuticular 2-0 rapid absorbable polygalactan.Careful vaginal and rectal examination is done to ascertain completeness of procedure and remove any swabs..
Intra operative antibiotics would reduce incidence of infection and wound breakdown.Metronidazole may be included to cover anaerobic contamination from fecal matter. Repair should be documented accurately and incident form completed

Posted by Manoj Babu  R.
(a) Justify your initial assessment [5 marks].

All women having operative vaginal operative vaginal delivery or perineal trauma should be assessed by an experienced practitioner.

During assessment enquiry should be made about the history of prolonged duration of second stage, type of episiotomy, face-to-pubis delivery, birth-weight of the baby more than 4 kg, history of shoulder dystocia and the use epidural analgesia. These are risk factors for a third degree tear. Any history of excessive postpartum hemorrhage should be asked for.

Examination should include assessment of general condition, pulse and blood pressure. Provide adequate analgesia by local infiltration or topping up epidural analgesia if necessary. Local examination should be done with adequate lighting and assistance. Look for any injury to the external and internal anal sphincter. The torn ends of the sphincter can usually be seen a s a dimple on either side of the anal canal. A rectal examination should be done look for any anal mucosal involvement and any possible button hole tear which may otherwise go undetected any may cause rectovaginal fistula later. Document the findings and degree of tear in the patient’s notes. One should initiate a critical incident reporting as per the local protocols.

(b) Which information would you give her in order to obtain informed consent for repair of the third degree tear? [6 marks].

She should be told that about 1 in 100 women develop third degree perineal tears after vaginal delivery. A meticulous repair is essential to prevent future complications like anal incontinence perineal pain and dyspareunia. After repair 60-80 % women remain asymptomatic at 1 year. She should be told that the repair will be undertaken in the operation theatre under regional anesthesia as it improves the quality of repair by providing adequate light, good instruments and muscle relaxation. She should be told that arrangement should be made for her to have a discussion with the anesthetist.

She should be told that some patients may remain symptomatic but usually they have only incontinence of flatus and urgency. It may affect her mode of delivery in subsequent pregnancy. She should be told about the possibility of knot migration after the repair and it may be expelled vaginally or rectally. She should told about the need for follow up to detect any residual defects and to consider secondary repair by a colorectal surgeon. She should be provided with written information explaining all these.

(c) She has a 3C third degree tear. Logically outline your intra-operative interventions to ensure optimum outcome. [9 marks].

In a 3C tear both the external and internal anal sphincter are torn. The repair should only be undertaken by an experienced practitioner who is formally trained. To optimize the outcome repair should take place in an operation theatre because of the availability of adequate lighting, appropriate instruments and good assistants. A regional or general anesthesia is preferred as it will relax the anal sphincter and help to retrieve the torn ends.

First the internal anal sphincter (IAS) should be repaired using interrupted sutures. Fine suture material like monofiolament 3 ‘0’ PDS or 2’0’ vicryl can be used as it causes less migration and discomfort The external anal sphincter (EAS) can be repaired by interrupted end to end or overlapping technique without any significant difference in outcome. An RCT comparing vicryl and PDS in the repair of EAS has shown no difference in the outcome measures. Burrying the knots under the superficial perineal muscles help to prevent knot migration. The perineal muscles and vaginal mucosa can be repaired continuous using 2’0’ vicryl rapid. The skin should closed using subculicular suture as this will reduce the short term pain compared o interrupted sutures.

A per rectal examination should be done at the end of the repair to confirm that sutures have not breeched the anal mucosa. Intraoperative and postoperative broad spectrum antibiotics should be prescribed as this will reduce chance of failure of repair.

Posted by Priti T.
prt

a]Patient should be assessed quickly.From the midwife the weight of the baby and the hx of prolonged labour is asked for this spontaneous delivery before 30 minutes.Patient is asked the details about her previous obstetric history.She should be asked about previous instrumental delivery,hx of delivery of large baby more than 4kg;associated problems of prolonged previous labour or shoulder dystocia.Previous repair of 3rd or 4th degree repair done is to be elicited.
She should be examined for pallor,tacycardia,hypotension to rule out PPH.Abdomen is examined to see that the uterus is well contracted post 30 minutes after delivery.She is examined digitally and by speculum if required to determine the apex of the perineal tear and to rule out cervical tear.Rectal examination is done after her consent to assess the integrity of anal sphincter complex and anal mucosa.

b] Patient needs to be informed that she has tear in her anal sphincter complex while having spontaneous delivery.This tear occurs in 1:100 of vaginal deliveries and its none of her fault in its occurence.She needs immediate repair for the same which is likely to be successful in 70-80% of the cases.For the repair she needs good lighting,immediate shift to O.T and additional analgesia in the form of either general anasthesia of topping up of epidural if the epidural cathetar is already in place.She should be explained that this surgery will have impact on her future pregnancies also.Her desire for future children should be elicited.She should be told that she will need CS for future delivery as further vaginal delivery can undo the perineal repair.She should be told the problems of flatus/bowel incontinence,fistula formation and sexual dysfunction if the repair is not done immediately.Written information is given for the same and proper documentation is done to take this informed consent.

c]Third degree3C repair should be done under all aseptic precautions in Sterile Opertion Theatre by properly trained surgeons or under proper supervision and good lighting.Bladder should be cathetarised or emptied.Patient is put in lithotomy position in general/epidural anasthesia.She is assessed again for the extent fo the injury by careful vaginal and rectal examination.
For the optimum results of the repair various layers should be identified properly and sutured in layers.Intact anal mucosa is identified.The internal sphincter is identified and repaired using interruppted or mattress 000 PDS[polydioxanone] delayed absorbable sutures.
The external sphincter complex is identified and sutured with 00 PDS using either end to end tecnique or overlapping technique.
Rest of the vaginal mucosa and perineal body is repaired by 00 polygalactin[Vicryl] rapidly absorbable sutures.For vaginal repair continuous non locking sutures of 00 Vicryl rapid is used to prevent vaginal shortening and post partum dysparunea.Perineal skin is sutured using sub cuticular rapid Vicryl stitches.Careful Vaginal and rectal examination is done to ascertain the completeness of repair and remove any swabs/tampoons.
Broad Spectrum antibiotics should be administered at the time of repair and 1 week after.Repair should be documented properly and the clinical risk management form is filled.
Posted by Ron C.
A.
A short history will help me to determine likelihood of a 3rd degree tear; previous deliveries/tears, prolonged labour/2nd stage, macrosome baby, GDM/DM, shoulder dystocia. Initial assessment of blood pressure, pulse rate, blood loss & active bleeding to determine whether resucutation and immediate transfere to theatre for assessment is needed. I’ll check whether i.v. access is present and blood group-&-save was taken. See whether patient is comfortable or has epidural anesthesia, as patient in pain more difficult to assess. Meticulous inspection of extent of tear to determine whether suturing in theatre is required, whether senior assistance is needed and to be able to explain patient what needs to be done. Combined vaginal-rectal examination is essential, as visual inspection only will often fail to identify 3rd degree tears.

B.
I’ll explain to her that the muscle around her anus is likely partially damaged, something which is difficult to prevent as it is difficult to predict. Repair in suboptimal circumstances increases risk for subsequent incontinence for flatus/stools, as well as dyspareunia. Repair under optimal circumstances, with regional anesthesia for pain and good exposure/lights yields good anatomical & functional result in most cases, whereas repair of poorly healed tears at later stage have a much less good outcome. I’ll explain there is a risk for infection, leading to wound breakdown; antibiotics will be given. She is likely to have perineal pain afterwards.

C.
Prior to embarking I’ll ensure good anesthesia, adequate (supine) positioning and good exposure (lights) throughout. I’ll clean the perineal region and drape to create sterile field. I’ll ask the anesthetist to give stat i.v. antibiotics (cefuroxim1.5 gram + metronidazol 500 mg). I’ll first identify the internal sphincter and repair it separately with PDS 3-0. Then I’ll identify the 2 ends of external sphincter, grasp them with alice clamps, dissect them free if needed and suture in overlapping fashion with PDS 2-0, making sure to approximate over the entire sphincter length. I’ll use continuous Vicryl 2-0 rapid for reconstruction of vaginal wall & perineum and skin subcuticular. I’ll do combine vaginal-rectal examination to ascertain good reconstruction of perineal body, sphincter tone, no sutures in rectum and no gauzes in vagina. I’ll finish with gauze and instrument counts
Posted by Arun J.
a -I would quickly gothrough her records to see for any potential risk factors(like big baby, malposition, premature bearing down, and use of midline episiotomy )for 3 rd degree tear,as a risk management strategy,though their predictiveness is low.I would check her BP and pulse to confirm stable haemodynamic status.I would palpate her uterus per abdomen to confirm that it is well contracted.I would inspect her perenium under good lighting and assistants to aid proper visualisation.I would look for the apex of the vaginal wound( as it could have extended up),bleeding vessels(as prompt identification and ligating them would prevent wound hematoma which is a deterrant to wound healing),and vaginal hematomas( as they are prone to infection and ultimately compromise the surgical repair).I would do rectal examination to see the tone and extent of external anal sphincter (EAS) damage ,and whether the internal anal sphincter(IAS) and rectal mucosa are involved so as to optimise repair.If there is any doubt regarding the structures involved i would classify it to a higher degree so to optimise surgical outcome.
b -I would explain the diagnosis to her. I would counsel her in a sensitive and empathetic way to allay her anxiety.I would brief her that it has longterm implications, if not repaired, such as fecal and flatus incontenence and its impact on quality of life.I would tell her that she requires surgical repair under regional anaesthesia in the theater for good outcome.Early repair is needed to optimise outcome.I would tell her that 60-80 % patients are asymptomatic after repair of external anal sphincter.If the symptoms persist during follow up, she requires specialist referal and additional procedures too . I would provide her with written information and document it.
d -I would give her prohylactic broad spectrum antibiotics IV to minimise infectious morbidity.Bladder needs to be catheterised to prevent post of urinary retention.Under regional anaesthesia ,with good lighting and assistants to help and with the consultant supervision i would do the repair.I would check the sharps and swabs count before starting the repair.Bleeding vessels are secured separately to ensure adequate haemostasis. IAS is sutured with 3\'0\' PDS or 2\'0\' vicryl.EAS is sutured with the same suture material in an overlap technique.I would take care to bury the knots under the superficial perineal muscles to prevent knot migration.I would also take care to meticulously suture all other perineal tears.I would check the sharps and swabs count after the repair also. I would finally check that adequate haemostasis has been achieved before completing the repair.I would then document the whole procedure .
Posted by J P.
a. Initial assessment would include elicitation of present obstetric history like whether labour was induced, duration of labour, weight of the baby, any difficulty encountered during delivery of shoulders. Expulsion of placenta will be noted. Delivery notes will be reviewed quickly to look for malpositions like persistent occipital posterior positions. Thorough clinical examination for pulse, blood pressure, pallor will be done to look for hypotension due to any post partum hemorrhage which may be associated with perineal tears.Iv access will be obtained and blood to be sent for cross matching in case of bleeding. Abdominal examination will be done to find whether uterus contracted or not. Speculum examination will be done to note the extent of perineal tear and the amount of bleeding.Per rectal examination to rule out rectal mucosa injury will be performed.

b.I will explain about the perineal tear in simple terms as injury to sphincter which is responsible for the continence of faeces and flatus.l will explain the need for suturing it under general/ regional anaesthesia,good lighting in operation theatre to delineate the extent of injury.The procedure will be explained as suturing the torn ends with absorbable suture material.The importance of doing the procedure for the continence of flatus and faeces will be informed.Frequent risks due to the procedure are infection,dehiscence,discomfort and perineal pain.Serious risks are incontinence of flatus and faeces,fistula,sexual dysfunction. .I will explain to her that post operative laxatives and antibiotics will be given to prevent infection and wound dehiscence.Perineal exercises will be taught and follow up will be done at 6-12 months by a gynaecologist with interest in ano rectal dysfunction..Consent will be obtained.Written documentation of the consultation will be done.

c.Suturing will be done by adequately trained or done under supervision with good assistance.In operation theatre under adequate anaesthesia the extent of injury will be delineated. Strict asepsis will be maintained. Intravenous antibiotics particularly for anaerobic cover followed by oral antibiotics will be given for 10 days to minimize the risk of infection. The ends of internal anal sphincter identified separately and sutured with 3 0 PDS.The ends of external anal sphincter are visualized and sutured by overlapping or end to end technique with 2 0 vicryl or 0 PDS which is associated with less discomfort and good long term spincter function.Vaginal mucosa is sutured by continuous locking sutures with synthetic absorbable material is associated with less discomfort and dyspareunia..Perineal muscles are closed in a interrupted fashion.Vaginal skin closure done by sub cuticular sutures with vicryl ,associated with less pain and wound break down. Rectal examination will be done to test the integrity of sphincter..Swabs and instruments count will be performed at the end of procedure.Incident form will be filled and documentation of the procedure will be done carefully. .
Posted by Manoj M.
a) Initial assessment involves taking a history from the attendant midwife regarding any difficulty at delivery like shoulder dystocia which may contribute to third degree perineal tears.
Other risk factors like occipito posterior position, birth weight of baby over 4kg or a midline episotomy should be ellicited from the midwife.
Pain relief used in labour should be known, if had an epidural this could be topped up for perineal repair.
Amount of bleeding should be quantified as perineal tear may complicate with a post partum haemorrhage.
Her pulse and blood presure should be examined to establish she is not haemodynamically compromised.
She should be examined abdominally to make sure the uterus is well contracted.
Perineal examination to confirm perineal tear and exclude underlying button hole defects as these unnoticed may complicate with recto vaginal/anovaginal fistula.

b)Description of the tear that involves the muscle of the anus should be explained to the patient.
If any underlying risk factors for third degree tear is established this explanation should be given to her, other wise she should be told this is an unavoidable injury.
Identifying and repairing the tear will prevent long term complications like faecal/ flatus incontinence, faecal urgency in most of the cases.
Explanation regarding repair in theatre will provide adequate analgesia and lighting for repair.
Regional anaesthesia/ General anaesthesia is required as this will help with muscle relaxation and provide adequate pain relief with the repair.
Risk of haemorrhage and may require blood transfusion.
Risk of infection will be minimised with prophylactic antibiotics.
Risk of wound dehiscence will be minimised with antibiotics and laxatives.
Explanation regarding after care of perineal wound and follow up should be explained.
A written consent should be obtained and clear documentation of all explanation in notes.

c)Perineal tear is classified as 3C Third degree tear when external and internal anal sphincter is torn.
If associated with haemodynamic compromises should encompass immediate resuscitation.
The tear should be examined and repaired by a trained obstetritian who has adequate training for third degree perineal repair.
Multidisciplinary approach with anaesthetics for regional/ general anaesthesia for repair.
IV access for fluids and drugs administration.
Bloods should be sent for full blood count, group and save as may need blood transfusion and exclude thrombocytopenia for regional anaesthesia.
Repair should be undertaken in operating theatre for asepsis, adequate analgesia, lighting, assistants and instruments.
External anal sphincter(EAS) should be repaired either by overlap or end to end technique as both has similar outcomes.
EAS should be repaired with monofilament polydiaxaone or braided polyglactin and both have similar outcomes
Internal anal sphincter should be repaired with finer sutures like 3-0/2-0 polydiaxaone/polyglactin sutures as theases are less irritant.
Surgical knots should be burried beneath superficial perineal muscle to prevent knot migration and irritation.
Introperative antibiotics should be given and continued as oral antibiotics for atleast 5 days as prophylaxis to prevent infection and wound dehiscence.
The operative notes should be fully documented if possible with sketches of the extent of tear and documentation of post operative plans including physiotherapy and obstetric consultant clinic follow up in 6-12 weeks.
An incident report should be made for risk management.





Posted by Ahmad A.
I would introduce myself as a new face going to evaluate her case. I would ask if she is having other possible complications like post partum hemorrhage due to other vaginal tears. I would ask to evaluate her vital signs and to have possible resuscitation measurements including blood sample for X matching, IV cannula and fluids. I would examine her to exclude other possible vag tears and to determine the degree of the tear. Third degree tar can be defined as it is involving the external and internal sphincter without tearing the anal canal. However the fourth degree tear should involve the anal canal. Both should be repaired with special arrangement and informed consent.

I would ask the patient to sign a consent form for repair. Repair should be done under regional or general anesthesia, with related consent form done by anaethetist. I would advise her to have the procedure as soon as possible without delay. I would explain the degree of the tear and the procedure of repair. I would tell her the tear involving the muscle controlling the defecation mechanism and should be repaired properly to avoid stool incontinence and rectovaginal fistula; I would tell that repair will not be a contraindication to have vaginal delivery with next pregnancy. She needs a special post operative care and follow up including antibiotic, laxative, pain killer, physiotherapy and long term follow up.

I would discuss the case with the consultant on call to handle the case for proper repair. I would prefer to perform the procedure in the main operating room with good lighting and assistant. I would fill the intraoperative antibiotic cover including broad spectrum antibiotic (Cephalosporin) and Mertonidazole. I would ask to insert a urinary catheter and to be kept for post operative period. I would examine her to identify the sphincter muscle, and repair the other tears controlling the bleeding sites. Internal anal sphincter should be repaired first identifying the angle closing higher, using PDS or vicryl 2/0 edge to edge interrupted closed sutures. External Sphincter should be repaired using overlapping sutures of PDS 2/0. I would continue repairing the vaginal wall, perineal muscle, subcutaneous tissue and subcuricular vicryl 3/0 for the skin. I would do vaginal and rectal examination at the end of the procedure. I would ask for instruments, gauze and swabs count. I would document all findings in post operative notes and fill the incident report form.
Posted by Maayka ..
nellie

a) I would review the patient’s antenatal records and delivery notes because there will probably be risk factors for a 3rd degree tear- such as her being a primigravida, having persistent occipito posterior position of baby in 2nd stage. Also check BW of infant if greater than 4.5kg and was an episiotomy given- check if it was midline. Use of forceps or a prolonged 2nd stage and shoulder dystocia will all be risk factors as well.

I will examine her after obtaining her verbal consent to check the perineum. There should be proper lighting in the delivery suite and a close inspection of the vaginal walls and a rectal exam to assess the extent of the tear will be done. The anal sphincter tone will be checked and disruption of the anal sphincter muscles, both external and internal anal sphincters. Other lacerations should be excluded since it may accompany a 3rd degree, depending on the cause.

b) I would explain to her that the repair should be done to avoid anal incontinence in the future or to at least reduce the chance of this occurring. I will let her know that it is best done in an operating theatre for her to have either general anaesthesia or epidural if the latter was not administered in labour. This will allow the relevant tissues, that is, the sphincter muscles to be brought together without tension.

She will be told that there may still be need in the future for secondary sphincter repair if upon review she is found to have anal incontinence symptoms. The risks of the repair involves infection because of its close proximity to the rectum and fistula formation, haematoma and superficial dyspareunia. If it is not repaired there is a definite risk of anal incontinence and scarring because of secondary intention wound healing.

c) The procedure would be conducted in an operating theatre with proper lighting, assistance and instruments. She would be placed in lithotomy position and before starting the perineum/ muscles are examined when anaesthesia administered to ensure extent is not greater than 3C. The anal sphincter components, external (EAS) and internal (IAS) are identified and repaired separately. The IAS is repaired with monofilament suture like 3-0 PDS in interrupted sutures and the EAS with 2-0 PDS or vicryl either overlapping technique or end to end anastomosis, ensuring that tension is not placed on the muscles. The knots should be buried beneath the perineal body to ensure it does not migrate to the surface and cause pain. The sphincter tone is checked at this point and at every rectal examination, it must be remembered to change gloves to avoid contamination of repair with fecal matter. The vaginal mucosa can be repaired with a continuous suture using vicryl rapide and the skin closed, after the fascia closed, with a subcuticular stitch of the same suture type. At the end, there must be a check of instruments, needles and swabs to ensure all are accounted for.
Posted by Osman A.
a)Her delivery notes should be reviewed for risk factors for 3rd degree perneal trauma include precipitated labour, induced labour and big baby. Perineal tear is associated significant physical and phypsychological impact, thus the extent of perineal injury should be assessed properly. Involvement of cervical tear should be rule out. The amount of bleeding should be noted. Blood pressure should be measured, if there is presence of hypotension resuscitation should be initiated. Full blood count and group and save should be send and intravenous access should be secured.
b) She should be explained that third degree tear is the injury involving anal sphincter. She should be ensured that success rate of repair is 60-80% after 12 months. She should know that she should be examined under anesthesia to establish the extent of her perineal tear. The risk of wound breakdown and knot migration should be explained. Long term complication like bowel or flatus incontinence should be informed to the patient.
c. The surgery should be done by well trained surgeon or under appropriate supervision. It should be done in operation theatre under anesthesia to ensure good lighting and good exposure. The procedure should be done with proper sterilization. Identification of correct anatomy is important before starting any repair. The internal and external anal sphincters are repaired with 3O PDS. The knots should be buried bellow the superficial perineal muscle to reduce risk of knot migration. The perineal body should be reconstructed to support the repaired anal sphincter. Vaginal and rectal examination should be done to check the integrity of the suture. Broad spectrum should be given to prevent infection.
Posted by A H.
AH
a)I will quickly peruse the antenatal record and more importantly the labour and delivery record. I will look for risk factors for anal sphincter injury. These include forceps delivery, innduction of labour, persistent occipito-posterior position,prolonged second stage, shoulder dystocia and nulliparity.
I will check the blood loss and previous haemoglobin to determine need for fluids or blood transfusion. This will be relevant if general anaesthesia is required.
A quick general examination followed by a meticulous examination of the perineum via per vaginal and per rectal examination will be done.
I will check if an epidural is in situ and if it requires top up. The anaesthetist will be asked to review the patient and discuss with her the type of anaesthesia to be used.
If she had postpartum haemorrhage, blood will be sent for a check haemoglobin.
b)I will explain to her the nature of the injury and that it needs to be repaired in theatre by a senior officer who is trained to recognise and correct the defect.She will be examined prior to the repair by the person doing it. It will be done under regional or general anaesthesia.
She will be told that the possible complications are perineal pain, dyspareunia, and knot migration to the perineum. Fecal incontinence and flatus incontinence can occur even after proper repair and repeat surgery may be required.
She would be advised that she would need analgesia and antibiotics and they would be safe to use if she is breastfeeding.
She will be given information leaflets and proper documentation will be done in her notes

c)The repair will be done in theatre where good lighting. proper instruments, and aseptic conditions are available. The patient will be placed in lithotomy position and an assistant will be required.
The repair will be done under general or regional anaesthesia so that the sphincter muscles will be relaxed for proper apposition without tension.
A fine suture will be used, either 3-0 polydioxanone (PDS) or 2-0 polyglactin.(Vicryl). The internal anal sphincter will be repaired separately with interrupted sutures using PDS. The external anal sphincter wiill be erepaired using an end to end or overlapping procedure as the results are equivalent with either.
Broad spectrum intravenous antibiotics will be commenced intraoperatively and continued orally postoperatively.
A rectal examination will be done after repair to ensure its integrity and all swabs, instruments and needles will be counted and accounted for.
Proper recording will be done.
Posted by syeda sajida M.
(a) I would like to know some details about the delivery like prolonged second stage, weight of the baby, occipito-posterior position, midline episiotomy and any previous 3rd or 4th degree tear, as all these factors are related to increased chance of extensive perineal trauma. I would like to assess patient\'s general condition(pulse, bp and amount of blood loss if having bleeding) to assess the need for resuscitation and to accelerate the process of repair. I will take consent and will do the examination under good light and analgesia.(entonox) I will do the vaginal examination and rectal examination to confirm the type of perineal tear for proper management and counselling of the patient.

(b) I would tell her that she has a tear down below near her back passage and it needs repair under anesthesia in good light and aseptic condition to have a good outcome. I will tell her the risk of infection, haemorrhage and incontinence of faeces and flatus incase of non-repairing of tear. She may need blood transfusion incase of heavy bleeding during repair. She will need long term follow up to be assured that there is no residual problem. I will explain to her the procedure and take informed consent for blood transfusion and repair of perineal tear.

(c) 3C tear is a perineal tear which involves the whole of internal as well as external anal sphincter. It should be repaired by an experienced surgeon or by a trainee under supervision to have good outcome. It should be performed in the theater in good light and with good assisstance under anesthesia which can be a regional block. I will reexamine her under anesthesia to confirm my findings and extent of injury. Internal Anal sphincter should be repaired with 3/0 pds because it has a high tensile strength and will take a long time to get absorbed. I can use end to end technique or overlapping technique as both of these techniques have the same results. External anal sphincter will also be repaired by the same technique by 3/0 pds. I will suture the vaginal mucosa with 2/0 vicryl by continous sutures and also the perineal muscle will be sutured in the same way. Skin should be approximated by subcuticular vicryl after proper hemostasis has been secured as it will reduce the post operative pain. On completion of the surgery I will do a vaginal and rectal examination and per rectum suppositries for analgesia not to be given. Intraoperative antibiotics(broad spectrum + metronidazole for anaerobes) should be given. I will make sure that my swabs, needles and instruments are correct and blood loss should be estimated. I will properly write the operative notes describing findings and all the steps of surgery.
Posted by zakaria M.
A:
Initial assessment involves hemodynamic stability of patient (B.P, pulse), amount of bleeding should be quantified as perineal tear may complicate with a post partum haemorrhage.
Assess patients level anxiety. A quick history from the attendant midwife regarding any risk factors i.e. difficulty at delivery like shoulder dystocia which may contribute to third degree perineal tears.Other risk factors like occipito posterior position,macrosomia or a midline episotomy should be ellicited from the midwife.Any comorbidities for anesthesia should be noted.Anagesia used in labour , if had an epidural this could be topped up for perineal repair.
She should be examined abdominally to make sure the uterus is well contracted. Detailed systematic perineal, and vaginal examination to assess severity of damage. Rectal examination to exclude any button hole tears as these may complicate with recto vaginal/anovaginal fistula.

B: Explain the extent of damage and anatomical structures involved Mehod of repair intended. And explain the need for repair in operation theatre under anagesia (regional or general) as immediate repair under adequate anesthesia is associated with improved outcome.Need of post operative antibiotics and risk of post op wound infection, dehiscence persistent anal symptoms, need for long term follow up will be explained.

C:
A good repair of sphincter is imperative as this is the factor most strongly associated with future continence
Repair under adequate anesthesia in theatre, with proper assisstance and supervision. Detailed examination before repair. .Accurate identification of extent of damge and structures involved, secure hemostasis.Use of delayed absorbable suture (2/0, 3/0 PDS), is associated with better long term outcome and less wound infection. Use broad spectrum antibiotics intraoperatively.All instruments swabs and needles should be accounted for.
Posted by Kp K.
KP

a)The initial assessment would aim to find the risk factors associated with third degree tear like nulliparity , epidural anaesthesia, prolonged 2nd stage ,persitent occipitoposterior position of fetus. Delivery of big baby, manoeuvres of shoulder dystocia also increases the probability of tear. Midline episiotomy can get extended to the anal sphincter. Enquiry about medical disorders to check for the fitness to surgery. General examination includes pulse and blood pressure for the hemodynamic status. Abdominal palpation to check whether uterus well contracted. Local examination to rule out nature and extend of tear , any other tears and whether patient is actively bleeding in which case repair should be expedited. Veinflon to be sited and bloods to send for FBC and group and save.


b)I would tell her the nature and the severity of the injury. The tear has involved the sphincter muscle that plays a role in anal continence. The importance to suture in theatre for proper assessment and also as there is availability of adequate lights, proper instruments and assistant. The need to suture under anesthesia preferably regional so that the muscle can be properly approximated as they are relaxed. The prognosis is good if sutured in theatre and under anesthesia. I would inform her the complications of anesthesia like nausea , vomiting and headache and surgical complications like infection , pain , bleeding , incontinence of flatus and faecal . Foleys Catheter for 12 hours as she may have retention of urine due to pain and anaesthesia. Intravenous antibiotic in theatre to optimise the risk of infection.

c)The repair should be done in theatre with regional anaesthesia and patient in lithotomy position. A through assessment of the severity of tear should be done prior to suturing. Also check for any other tear involving vaginal walls or parauretral .
In 3c tear there is involvement of both external and internal anal sphincter.
The external anal sphincter (EAS) should be sutured with overlapping or end to end technique as both has equivalent outcome. The suture material use would be either monofilament polydioxane or modern braided polygalactin . The internal anal sphincter should be suture with interrupted technique and fine suture should be used as PDS 3-0 or vicryl 2-0 for less discomfort and irritation. The knot should be buried beneath the muscle to prevent knot migration to the perinal skin which can be very uncomfortable and painful. Perrectal exnamination to ensure suture not gone through rectum as can lead to fistula formation. Foleys catheter to be inserted . Swabs, instruments and needle should be checked. Proper documentation of nature of injury, technique and suture material used.. Postoperative plan for antibiotics and laxatives to decrease incidence of wound dehiscence. Incident form should be filled.
Posted by PAUL A.
a) The delivery notes should be reviewed to look for any risk factors for third degree tear such as big baby >4.5 kg, induction of labour or persistent occipito posterior position delivery what difference does this make? If the baby weighed 1.5kg after spont labour, would you walk away without examining her? You were asked to JUSTIFY – so why is this Hx important?. Consent for examination should be obtained. Adequate analgesia should be ensured before the examination (1) . Systematic examination including per vaginal and per rectal (1) should be done to assess the degree and extent of injury. The findings should be explained to the woman.
b) The nature of procedure and purpose what is the nature and purpose? ; Benefits of procedure should be explained what are the benefits of the procedure? If this is sufficient, then you will write the same thing if you were asked about CS or hysterectomy and expect to get marks. The examiner wants to know that you know the nature, purpose, benefits, risks of the operation . Serious risks (1) such as flatus and fecal incontinence, wound infection and dehiscence needing secondary repair and anovaginal fistulae should be explained. Frequent risks include pain and bruising. Alternative treatments which in this case is none should be explained. It would be done in theatre under regional or general anaesthetic (1) and should be seen by anaesthetist before shifting to theatre. Information leaflets (1) should be given and any questions that the patient may have must be answered honestly.
c) Thorough systematic examination should be done by PV and PR examinations (1) to assess the extent of injury under anaesthetic as the anal sphincter is relaxed under anesthetic. Appropriate identification of structures is crucial for proper anatomical repair and sucessful outcome. Strict asepsis should be maintained and IV broad spectrum antibiotics (1) according to unit protocol should be given to prevent wound infection. Adequate light and use of assistants for proper repair is essential. The person performing the procedure should be competent (1) or under supervision in the procedure as inexperienced attempts at repair is associated with adverse outcome. Internal anal sphincter should be repaired by interrupted stitches (1) using PDS 3-0; External anal sphincter can be repaired by either end to end or overlapping method as either has been shown to be associated with similar outcome. This should be done by PDS 3-0 or Vicryl 2-0 (1) . After repair, a thorough PV and PR examination should be performed to check the integrity of repair and to rule out inadvertent placement of suture in the rectal mucosa. Swabs, needles and instruments should be accounted for (1) and accurate documentation is vital.
Posted by PAUL A.
A. Detailed history including the induction of labour, use of epidural analgesia, duration of second stage of labour, malpositions, birth weight of the baby, any difficulty experience in delivering the shoulders, episiotomy(especially midline) should be enquired what difference does this make? What will you do differently in women with / without these risk factors? . Even though all these factors increase the incidence of third degree perineal tears but none of them is a good predictor.
Clinical examination includes vital signs and assessment of amount of blood lost. The perineum should be carefully assessed for the presence of tear and its severity if present. The anal sphincter should be assessed for any discontinuity and the apex of the vaginal tear should be assessed. Per rectal examination should be done to rule out any button hole tear in the anal epithelium PR examination is essential to confirm injury as second / third degree, not just to look for a button-hole injury . The fitness for anaesthesia should be ascertained.

B. Women should be explained about the injury sustained to the anal sphincter during child birth. These injuries are often not predictable and also not preventable. 9 out of 100 women undergoing vaginal delivery are likely to suffer from this. The repair of the perineum is needed to prevent development of flatus and faecal incontinence (1) . Repair done under analgesia or anaesthesia what type? will improve the outcome. Repair is successful in 60-70% ? meaning?? Are you suggesting that 30-40% of women with third degree tears will be incontinent?? of the patients. Intra operative complications include anaesthetic complication and haemorrhage. The short term complications like perineal pain, suture migration and infection. Long term complications include faecal urgency, faecal incontinence, flatus incontinence (1) , fear of commencing sexual relationship. When properly repaired it will not have any impact on future child birth. The repair will not interfere with her breastfeeding. Informed consent should be taken.

C. Procedure should be carried out in operation theatre for the advantage of strict asepsis, good lighting, appropriate instruments, and necessary assistance. Performing under regional analgesia or general anaesthesia (1) would relax the sphincter torn ends and hence retrieval and approximation without tension can be done. Broad spectrum antibiotic along with metronidazole for anaerobic coverage should be given to combat infection (1) these are prophylactic antibiotics due to faecal contamination. Infection increases wound disruption and fistula formation. The procedure should be done by appropriately trained person or trainee under supervision (1) . Careful examination under anaesthesia should be done to confirm the findings. The internal anal sphincter should be approximated by interrupted suturing using polydiaxanone 000 or poly glactin 00 (1) . The external anal sphincter should be approximated either by end to end or by overlapping technique using polydiaxanone 000 or poly glactin 00 (1) . Both have similar outcome. The perineal muscles are approximated after suturing the vaginal mucosa by continuous unlocking sutures to avoid foreshortening of vagina. The perineal skin should be sutured (1) how and with what? .After the surgery vaginal tampons should be removed. Swabs and sharp instruments counts has to be checked. Per rectal examination should be done to ascertain the adequacy of the procedure this is not the purpose of PR – it is to ensure that sutures have not been inserted through the mucosa . Meticulous haemostasis should be achieved as haematomas will cause wound disruption and infection.
Posted by PAUL A.
=======================================
Markd.

a)
I will ask history from the midwife for any risk factors that may have caused the tear like prolong labour, instrumental delivery READ THE QUESTION ,big baby or shoulder dystocia WHY? JUSTIFY. Will you walk away if the woman had no risk factors for third degree tear? If not, what difference will the Hx make? .these factors may also cause traumatic PPH.i will ask the mother about how she is feeling and asses her emotional and psycological state,I will ask if she has seen and touched the baby.I will assess general wellbeing by checking pulse ,BP,respiratory rate,tempearature,hydration,to confirm hemodynamic stability. I will assess her pain relief. If she is in pain she will need epidural top up dose did the question say she had an epidural? . I will do a per abdomen examination to confirm well contracted uterus. I will inspect the vulva for any active vaginal bleeding,I will gently asses the tear in lithotomy position by vaginal and rectal examination to confirm that there is third degree tear (1) .I will inform her the findings.There is no proven benefit by endoanal ultrasound to diagnose the degree of tear in immediate post partum period. will you tell the woman that you will be performing a rectal examination?

b)
I will tell her that she has had a perineal tear during labour which involves her anal sphincter (1) . It needs assesment and repair in the operating room under adequate analgsia and relaxation by person with formal training in perineal tear reapairs. If it is left unrepaired (1) she willl have long term anal incontinence and affect her quality of life. The repair has good success rate and 75%of women are asymptomatic at 1 year of follow up.Repair will be done with delayed absorbable suture materials which will be absorbed by 6-12 weeks.However there is a risk of knot migration.
After repair we will put a catheter to drain urine for 24 hours till her pain settles and she is fully ambulant.
She will need to take laxatives and stool softners for 10 days post operatively to prevent hard stool from disrupting the repair. She will be given adequate pain killers.
She will be asked to follow up at 6 weeks, 3 months, 6 months and 1 year at the dedicated perineal clinic to check for any incontinence does your clinic follow women up this frequently? .She will be given pelvic floor exercises at 6 to 12 weeks and this will strengthen her pelvic floor and perineal muscles. She should use a reliable contraception to aviod pregnancy till then.She should report if she suffers from stool or flatus incontinence. I will proved her with written information. Plan for subsequent deliveries will be discussed at the time of discharge YOU HAVE NOT ANSWERED THE QUESTION – which info will you give her in order to obtain informed consent for repair of third degree tear??? .

c)
Under adequate relaxation what is relaxation??? She needs analgesia / anaesthesia NOT relaxation after proper painting and draping and emptying the bladder,I will check for the retracted ends you will perform examination under anaesthesia first of external anal sphincter and try to identify the internal anal sphincter fibres. I wll retrive the ends of sphincter ? internal or external?? .I will approxiamte them end to end with interupted 2-3 stitches with 2-0 vicryl or PDS 3-0 PDS . Overlapping techinque has similar outcome to end to end approximation. Vicryl and PDS can be used with equivalent outcome. I will separately suture the internal anal sphincter fibres (1) . I will bury the knots under superficial perineal mucles to prevent knot migration (1) . I will suture perineal muscles and vaginal mucosa with continous sutures and approximate skin with 2-0 subcuticular vicryl rapide (1) .This will minimise the perineal pain.I will do a PR examination to check integrity of the repair THIS IS TO ENSURE THAT SUTURES HAVE NOT BEEN PLACED THROUGH MUCOSA .I will insert a foleys catheter for bladder drainage (1) and insert a diclofenac suppository perectally for post of pain relief.
I will check the sponge mop instrument count (1) .
Prophylactic antibiotic augmentin and metronidazole will be given at the start (1) if so, why write it at the end? of repair because the consequences of infection and wound dehiscence are grave.
Posted by PAUL A.
a) I would obtain a history to assess her risk factors for a 3rd degree tear. This includes a history of a previous 3rd or 4th degree tear, use of epidural analgesia and fetal macrosomia. If there is a history of malposition (such as occipito-posterior)or compound presentation, this increases her risk. A midline episiotomy also increases the risk of a 3rd or 4th degree tear what difference does Hx of risk factors make? JUSTIFY – will you do a different examination in a woman with risk factors? If not, what is the point? She has already delivered and someone has looked at the perineum and called you to take a look. Risk factors are irrelevant at this point . I would ask if the placenta has been delivered as this might affect the ease at which an examination of her perineum can be performed.

I would ensure that the patient has adequate analgesia (1) and that there is good lighting before conducting the examination. These will aid visualisation of the structures damaged.

A vaginal examination will reveal the depth of the tear both cranially and inferiorly. A par rectal examination will enable an assessment of the integrity of the rectal mucosa and anal sphincter (1) ? position of the woman. Will you tell her you will be performing a PR? . If there is any doubt about the extent of sphincter involvement, advice from a senior obstetrician and gynaecologist will be obtained. If this is unavailable, an assessment in theatre will be made as there is better lighting.

I would site an intravenous cannula as antibiotics will be required if there is a 3rd or 4th degree tear. Blood will also be obtained for a full blood count and group and save as perineal trauma can cause postpartum haemorrhage

b) The extent of the tear will be explained WHAT WILL YOU SAY? . The nature of the repair will be explained WHAT IS THE NATURE OF THE REPAIR? The examiner wants to know that you can explain these facts to women . It will be conducted under regional or general anaesthesia (1) .

The benefits of primary repair of a 3rd degree tear are reduced risk of bowel symptoms such as incontinence of flatus or faeces and urgency (1) . The risks of the procedure are a wound infection, knot migration, haematoma, dyspraeunia, or an inadequate repair leading to bowel symptoms (1) . There is also a small risk of venous thromoboembolism.

Antibiotics and stool softeners will be prescribed to reduce her risk of infection and wound breakdown through straining. Discharge from hospital will depend on how soon she defaecates following the procedure. Physiotherapy will be commenced whilst she is an inpatient and pelvic floor exercises should be maintained.

The alternative to a primary repair is to allow wound healing by secondary intention IS THIS AN ALTERNATIVE? HAVE YOU EVER PRESENTED THIS TO A WOMAN AS AN OPTION?? (-1). WHAT WILL YOU DO IF FOR SOME REASON SHE CHOSES THIS OPTION? . The benefit of this is an avoidance of the risks of surgery. The disadvantages are a high risk of bowel symptoms and poor cosmetic effect. Wound healing by secondary intention may take up to 12 weeks and as a consequence, may become infected. An effective primary repair is less likely to result in bowel symptoms compared to a delayed or secondary repair.

c) All swabs, instruments and sutures will be counted at the start of the procedure to avoid accidental retention in the patient.

Broad-spectrum antibiotics (1) and antibiotics to cover anaerobes will be given intravenously to minimise bacteraemia and therefore reduce the risk infection. Good technique is required and supervision (1) of the procedure by a senior obstetrician and gynaecologist should be requested if there is uncertainty regarding the repair.

The ends of the internal anal sphincter should be identified and repaired separately to the external anal sphincter (EAS). It should be repaired with a fine stitch what is a fine stitch? to avoid knot migration towards the rectum or superficially towards the skin. A delayed absorbable suture such as polygalactin will allow adequate healing and reduce the risk of migration.

An overlapping repair of the EAS should be performed as this is less likely to result in urgency of defaecation compared to an end to end repair ? evidence??? . Repair of the EAS performed with a braided why does it have to be braided? Why is a monofilament suture unsuitable? What are the disadvantages of using braided sutures in an area with significant risk of infection? delayed absorbable suture such as polygalactin is less likely to result in knot migration and irritation compared with polydiaxanone. The knots should be trimmed to avoid knot migration buried by superficial perineal muscles . A rectal examination should be performed to check the integrity of the repair what are the features you assess?? The purpose of PR is to ensure that sutures have not been placed through the mucosa before commencing with repair of the vaginal walls and perineum. This will also ensure that no stitches have been place in the rectum (1) as this can cause a fistula.

A non-locking repair of the vaginal walls commencing from the apex of the tear should be performed with a rapidly absorbed suture. A non-locking repair is less likely to cause dyspraeunia and does not shorten the vaginal length. Failure to secure the apex could result in a haematoma or bleeding.

YOU WOULD HAVE RUN OUT OF SPACE / TIME HERE. You need to be able to distinguish between essential information that carries marks and information that might be correct but unnecessary for the question
A continuous repair of the perineal muscle should then be performed followed by subcuticular stitches to the skin. Subcuticular stitches are associated with better cosmesis, healing and less pain compared with interrupted stitches. A vaginal examination should be performed to ensure that all tears have been sutured.

A rectal examination should be performed again to ensure that no stitches have been placed in the rectum as this could result in a fistula.

All sutures, swabs and instruments should be counted again to ensure that none have been left within the patient.

Stool softeners should be prescribed to prevent straining and wound dehiscence. Oral broad spectrum antibiotics and antibiotics that cover anaerobes should be prescribed for 1 week to reduce the risk of infection and wound breakdown.

Thromboprophylaxis should be considered if the patient has other risk factors such as smoking and a BMI greater than 35.
Posted by S M.
SM reply.
a)
On initial assessment , I would like to quickly ellicit a brief history from the woman regarding significant medical disease like hypertension , any predisposing factors for perineal tear like primigravida, delivering > 4 kg baby , occipitoposterior position or percipitate delivery.I would check the woman\'s pulse , BP, SPO2 and the estimated blood loss so far so as to ascertain if resusitation is required. I would like to arrange for FBC, cross match 2 units PRBC.I will check if the uterus is well contracted and proceed to do a speculum examination to visualise the apex and grade the perineal tear.I would like to do a PR examination to rule out a button -hole tear of the anal epithelium .I will arrange for repair of the same in Operation theatre after obtaining consent from the woman.I will inform the consultant.
Posted by S M.
SM reply contd.
b)
Inorder to repair a third drgree perineal tear , I would explain the situation to the woman. The need to repair the tear in OT and need for anaesthesia would be explained. Antibiotic covearge, need for laxative and physiotherapy postoperatively will be explained.Short term risks of perineal pain and foley\'s catheter and long - term risks of possible anal incontinence and need for elective LSCS would also be explained. Probable need for blood transfusion will be explained.
c)
Intraoperatively,I will ensure that patient is under adequate anaesthesia genaral/regional. She must be placed in lithotomy position.Aseptic precautions will be maintained.Adequately skilled team and adequate light is imperative for a good repair.Examination under anaesthesia is carried out to rule out any cervical and vaginal tears.PR will be done to rule out button-hole tears. The IAS is repaired with 3-0 PDS, and EAS with 2-0 PDS.Vaginal epithelium is sutured with continous non- locking sutures with 2-0 PDS. Perineal body is sutured 2-0 PDS to support the anal sphincter sutures.To prevent knot migration , knot must be burried in the muscle.Skin is sutured with vicryl 2-0 rapid, subcuticular sutures.Foley\'s catheter will be inserted. Tampoon and needle count would be checked.
Posted by PAUL A.
TSH
A third degree tear is one that ivolves the skin,vaginal wall ,perinea muscle and anal sphincter and initial assessment and detection is important to allow early repair and avoid morbidity (1) .
I would ask about the situation around the delivery, wether there was fetal macrosomia, delivery in occipito posterior position, wether operative vaginal delivery read the question – spontaneous vaginal delivery was conducted , wether there was shoulder dystocia and how managed . I ask if an episiotomy done as midline ones may extend. I would ask wether in her obstetric history if she had a previous tear and was it repaired and if was continent after you were asked to JUSTIFY – so why take this Hx? What will you do differently if the woman had every risk factor compared to no risk factor? . On examining her how will you perform this examination? I would see the extent of the tear and wether the external sphincer(IIIA <50% torn IIIB > 50% torn) was torn and wether this was associated with internal sphincter (III C tear).I would look for other tears and do a rectal examination (1) to see if anal wall is intact. However proper assessment of the degree can only be done after giving regional or general anesthesia will you ensure adequate analgesia before examining her? .


B) I would explain to the patient the situation and that the sphincter that control her stools was torn during delivery (1) and need to be repaired to avoid developing problems with continence. I will tell her that repair will need to be done under regional or general anesthesia (1) and in the operating theater by an experienced person and that she will need to have antibiotics to guard against infection as the area is near the anus. Will tell her that she will be fitted with a urinary catheter after the procedure as she will be at risk of urinary retention and that she will be given laxatives for two weeks to loosen stools to prevent injury to wound by hard stools. Will tell her she will feel some pain after operation and will be given pain killers. I will supply her with written information and even draw to her what will be done before consenting her.
suggest you look at a consent form to see what needs to be filled – name of procedure / description, intended benefits, frequent risks, serious risks, additional procedures that may be needed; analgesia / anaesthesia, information leaflets, discussion of any alternatives


C) Procedure should be done by consultant or under his supervision (1) , in the operating theater under good light and proper antiseptic preparations. She is given intravenous antibiotics (1) . She is given regional or general anesthesia (1) to aid in relaxing the anal sphincter so as to identify the retracted torn ends . The area is explored under anesthesia and extent of tears identified The internal sphincter is sutured with delayed absorbable interrupted sutures which size? . The ext sphincter edges sutured either end to end or overlaping with delayed absorbable suture (1) ,both methods giving same results in healing . The vaginal wall and perineal muscles are sutured with continuos delayed absorbable suture is this what you use for vaginal wall and perineal muscle?? and skin with subcuticular or interrupted suture vicryl rapid. Proper hemostasis and swab count are done will you do PR at the end? . At the end patient fitted with Foleys catheter (1)
Posted by PAUL A.
a)History of place of delivery such as whether delivery occurred while conveyance or in toilet, attended by skilled staff/midwife or unattended , as in unattended deliveries because of lack of perineal support more tears will be expected ?? relevance and ?? evidence. Is there any evidence that tears are more common with hands off / hands poised techniques compared to hands on? . I would also enquire about the parity of patient as in primipara because of tough perineal muscles extension of episiotomy is more possibility. Previous history of any perineal surgery in the patient which will make her more vulnerable for trauma of labour . weight of the baby is more important to know because macrosomic baby cause extension of episiotomy or tears. Time of onset of active labour & time of delivery is to be taken in account as precipitate labour is associated with more extensive tears . If labour was prolonged possibility of abnormal presentation may be a possibility this is irrelevant – the woman has already delivered and whether these risk factors are present or not will not alter what has already happened . Patient’s ethnicity is also important as in some African patients because of female circumcision there will be scarring of vulva causing more damage & tears. In women of asian origin , distance between introitus & anus is small, causing more extension of episiotomy esp, midline episiotomy as well as tear this is totally irrelevant and there is no evidence to support your statements . I would also enquire about type of episiotomy if given , as midline episiotomy is more associated with third degree perineal tears. On examination , general condition of the patient to be assessed quickly to rule out hypotension, tachycardia, cold clammy skin, severe pallor as these findings may suggest severe blood loss associated with the tear – PPH. Per abdominal examination to rule out uterine atonicity . With her consent , I will do per vaginal examination in lithotomy position under good light & adequate analgesia (1) to confirm the degree of tear. I would like to do PR examination to rule out rectal injury PR is needed to confirm second / third degree tear not just to rule out rectal injury .
B) Sympathetic approach in explaining situation is essential . I will inform her , preferably in presence of her partner that while delivering her baby, injury has occurred involving her vagina & extended upto the end of excretory passage what is this?? Presume no woman will know where their excretory passage is but all will know where their anus is . I will inform that vaginal tears are common during delivery. Likely cause in her case should be explained . I will tell her she requires a surgical procedure which will be better taken in operation theatre . She will require anaesthesia / analgesia (1) . She may require blood transfusion if associate with PPH . I will explain her the procedure & its complications like infection, dysparunia,wound dehiscence, faecal incontinence or fistula formation (1) . I will also tell that during postoperative period she may require laxatives to avoid hard stools.

c) After stabilizing her general conditions & with informed consent ,I will post her for repair of tear as soon as possible,as delayed surgery may increases the chance of infection.I will do it in operation theatre,under good light & good exposure,for which I will put her in lithotomy position. Procedure to be done by appropriately trained person or trainee under supervision (1) . Under adequate anesthsia (1) & with all aseptic measures,I will start with the repairing of anal sphincter which one? ,with an delayed absorbable synthetic suture like Vicryl 3-0,with intermittent interrupted stitches.Once sphincter is sutured ,I will suture the vaginal mucosa,& muscle in layers with Vicryl rapide no 2-0 ,continuous non interlocking suture . Skin will be repaired by same suture material with a subcuticular stitch.After the procedure,I will do PR examination,to rule out any extension of the stitches involving rectum (1) & will insert analgesic pessary to reduce postoperative pain.
Posted by PAUL A.
I would like to know delivery details and previous obstetric history to find out risk factors for third degree tear ? relevance. She has already given birth and the presence / absence of risk factors will not alter what has already happened or what you will do . Previous third degree tear, primipara, big baby, delivery complicated shoulder dystocia, head delivery as occipitoposterior and midline episiotomy are associated with a higher risk of third degree tear. Presence of these factors would favour this diagnosis although it would not change the management so what is the point then? By your own admission, it is a waste of time
A proper vaginal and rectal (1) examination in lithotomy position in presence of good light and adequate analgesia (1) should be performed to assess the degree and severity of perineal trauma. If no analgesia is on-board, she should be transferred to theatre for examination under anaesthesia (EUA) and repair of the tear. It always better to over-estimate the type of tear rather than under-estimate.
She should be informed about the diagnosis and its implications. The name of the operation and what it involves should be discussed. Benefits of doing operation and the serious and frequently occurring risks should also be discussed and documented in her notes how does the examiner know that you know the implications of third degree tear, benefits / risks of the operation??? . If she declines the surgery, she should be informed about its consequences in form of incontinence for faeces and flatus. She should also be informed about any additional procedure needed per-operative such as repair of rectal mucosa you were asked to take consent for repair of third degree tear or colostomy and need to involve colorectal surgeon. She should also understand that despite good surgery there is a possibility that she might continue to have symptoms of incontinence (1) . Her wishes should be taken in consideration. An information leaflet (1) should be provided.
It should be sutured in theatre in good light and in adequate analgesia by experienced doctor or under supervision (1) . EUA including rectal examination should be done (1) . Internal sphincter should be sutured with PDS and interrupted sutures. External sphincter can be sutured with PDS (delayed absorbable material) as well either by overlapping technique or end to end anastomosis (1) . Recently few studies showed better outcome following overlapping method than end to end anastomosis. Knots should be buried under muscle layer which muscle? . Vaginal mucosa and muscle layers should be sutured by continuous stitches with vicryl rapide. Subcuticular skin stitches would reduce amount of pain after this surgery (1) . Intra-operative IV antibiotics (1) should be given and oral antibiotics should be continued next 10 days along with analgesia and stool softnors. Foley catheter (1) should be left for few hours after regional analgesia. Rectal examination should be done to check the integrity of rectal mucosa (1) and rectal suppository can be given at the same time. Swabs, sharps and instruments count should be done after the procedure. Documentation should be done. Incidence from should be filled. She should be referred to physiotherpy for pelvic floor excercise. A follow up appointment should be made with consultant in 6-8 weeks.
Posted by PAUL A.
X

a. I will assess her by taking a quick history in regards to age, parity, comorbidity for anesthetic risk such as underlying heart disease, hypertension anemia or diabetes which could predispose to infection READ THE QUESTION – HEALTHY 35 year old woman – this is because the examiner wants to focus on specific issues . The risk factor for the tear also illicited, such as instrumental delivery SUGGEST YOU READ THE QUESTION AGAIN , macrosomic baby, dystocia, OP position or type of episiotomy performed to facilitate my counselling later on ? RELEVANCE OF RISK FACTORS – THE TEAR HAS ALREADY OCCURRED . Her vital signs are taken to aseses her hemodynamic status and the amount of blood loss estimated for any resuscitation required. I would deliver the placenta if the third stage was incomplete to facilitate my vaginal assessment. I would put her in a lithotomy position to facilitate my vaginal asessment and the intergrity if the anal tone assessed via a per rectal examination (1) .


b. I would inform her that she sustained an injury from the vagina to the anal sphincter (1) which could occur in about 1 in 100 vaginal deliveries. Primary repair done properly could make her better in 60 to 80% are 20-40% of women ‘no better’ after primary repair?? of the time. I would explain that secondary repair of the tear carries a worse outcome and should be done promptly for optimum results. The anesthetic risk is minimal and at is essential a good assessment and repair. In spite adequate repair there is still possibility of flatus or fecal incontinence (1) . There is also risk of rectovaginal fistula occurring but it is rare. Antibiotics wil bee given for prevention of infection and might be required pot operatively. Laxatives also will be given post operatively for anastomotic intergrity. Blood transfusion may be required if there was excessive bleeding during procedure . Option of a caesarean section will be given for future pregnancy. A formal followup will be done and if required a referral to colorectal surgeon is this necessary to obtain consent for the operation? .

c. The procedure should be done by a obstetrician with a adequate training in the management of third and fourth degree tear (1) ? trainee under supervision . It should be done under regional or general anesthesia (1) for thorough assessment , proper identification of the perineal anatomy and repair. It should be done in the operating theater with adequate lighting and assistant. The procedure should be done under aseptic technique with antibiotic (1) coverage preferably such as cefuroxime with metronidazole. Proper speculum used for viewing ? EUA . PDS sutures or polyglactin sutures uses such as vicryl 2/0 for repair. The internal sphincter should be sutured end to end with interrupted sutures (1) while the external sphincter could be done either end to end or overlapping interrupted sutures (1) . Burying of the knots is recommended as it prevents knot migration. After suturing the mucosa and skin with what?? a per rectal examination done to confirm no penetration of sutures to the anal mucosa (1) have taken place as it could result in a fistula ? foley catheter .
Posted by PAUL A.
a) Initial assessment of the patient would include taking a quick history from the midwife about the weight of the baby and course of labor. Macrosomic baby (>4.5kg) and dysfunctional labor is associated with perineal tears.Equire about the type of episiotomy given,midline episiotomy is associated with extension and tears ? relevance – will you walk away if the baby weighed 1.9kg?? The tear has already occurred and risk factors are irrelevant .
Patient should be examined to assess the amount of blood loss and need for resuscitation.
General examination should include P,BP,T and respiratory rate.Tachycardia and low BP indicate the need for resuscitation. Two large bore canulae are inserted and iv fluids started.Blood is grouped and crossmatched,clotting profile and U&E done there is no indication in the question that there is PPH
Vaginal and rectal (1) examination done to ascertain the extent of perineal injury and any other associated vaginal or cervical laceration should be noted.Accurate assessment of extent of perineal injury is very important medicolegally and for adequate repair.
b) Nature of injury what is the nature of the injury? should be explained to her.She should be told that it is one of the complications of vaginal delivery which can happen in 0.5-1% cases.It requires repair,which would be performed under anesthesia (1) as per RCOG recommendations.Prognosis is excellent after adequate repair.If left untreated she may end up with complications such as high risk of infection fistulas,urinary and anal incontinence (1) ,and sexual dysfunction. Postoperatively.she would be given adequate analgesia for pain relief,and laxatives to soften her stools.She would be followed up by colorectal surgeon ,who would assess her condition postnatally and advise regarding her future pregnancy and deliveries do you need this to obtain consent? You have not explained the risks of the operation .Written information (1) is given and consent obtained .Clear documentation of all the information given and intended procedure is very important.
c)It is recommended by RCOG that the repair should be conducted by an appropriately trained practitioner or trainee under supervision (1) ,as inexperienced attempts at anal shincter repair may contribute to maternal morbidity especially anal incontinence.This should be done in operating theatre ,under general or regional anesthesia (1) .This allows repair to be performed under aseptic conditions with appropriate instruments, adequate light and an assistant.
EAS can be repaired with PDS or Vicryl with equivalent outcome.
Repair of IAS is performed with fine suture size i.e 3-0 PDS or 2-0 Vicryl (1) which size suture for EAS? .This causes less irritation and discomfort.Repair of EAS by overlappindg or end-to-end (1) approximation can give equivalent outcome.IAS may be repaired separately with interrupted sutures. During the repair of anal sphincters surgical knots should be buried beneath the perineal muscle to prevent knot migration (1) to skin. Long acting and non absorbable sutures are associated with possibility of knot migration to the suface.
Vaginal mucosa is sutured with locking stitches. Perineal muscles are sutured with interrupted 2-0 polygalactan is this different from vicryl? stitch.
Skin sutured with subcuticular 2-0 rapid absorbable polygalactan so what did you use for vaginal mucosa and perineal muscle if you are using rapid absorbable here?? .Careful vaginal and rectal examination is done to ascertain completeness of procedure this is to ensure you have not placed sutures through mucosa and remove any swabs..
Intra operative antibiotics (1) would reduce incidence of infection and wound breakdown.Metronidazole may be included to cover anaerobic contamination from fecal matter. Repair should be documented accurately and incident form completed
Posted by PAUL A.
(a) Justify your initial assessment [5 marks].

All women having operative vaginal operative vaginal delivery read the question – spontaneous vaginal delivery or perineal trauma should be assessed by an experienced practitioner.

During assessment enquiry should be made about the history of prolonged duration of second stage, type of episiotomy, face-to-pubis delivery, birth-weight of the baby more than 4 kg, history of shoulder dystocia and the use epidural analgesia. These are risk factors for a third degree tear ? relevance?? Will the presence / absence of these risk factors determine the nature of the tear / alter what you do? . Any history of excessive postpartum hemorrhage should be asked for.

Examination should include assessment of general condition, pulse and blood pressure. Provide adequate analgesia (1) by local infiltration or topping up epidural analgesia if necessary. Local examination should be done with adequate lighting and assistance. Look for any injury to the external and internal anal sphincter. The torn ends of the sphincter can usually be seen a s a dimple on either side of the anal canal. A rectal examination should be done look for any anal mucosal involvement and any possible button hole tear this is essential for diagnosis of third degree tear and is not just to assess mucosal involvement which may otherwise go undetected any may cause rectovaginal fistula later. Document the findings and degree of tear in the patient’s notes. One should initiate a critical incident reporting as per the local protocols.

(b) Which information would you give her in order to obtain informed consent for repair of the third degree tear? [6 marks].

She should be told that about 1 in 100 women develop third degree perineal tears after vaginal delivery. A meticulous repair is essential to prevent future complications like anal incontinence perineal pain and dyspareunia (1) . After repair 60-80 % women remain asymptomatic at 1 year. She should be told that the repair will be undertaken in the operation theatre under regional anesthesia (1) ? GA as it improves the quality of repair by providing adequate light, good instruments and muscle relaxation. She should be told that arrangement should be made for her to have a discussion with the anesthetist.

She should be told that some patients may remain symptomatic but usually they have only incontinence of flatus and urgency. It may affect her mode of delivery in subsequent pregnancy. She should be told about the possibility of knot migration after the repair and it may be expelled vaginally or rectally. She should told about the need for follow up to detect any residual defects and to consider secondary repair by a colorectal surgeon. She should be provided with written information (1) HAVE YOU EXPLAINED THE RISKS OF THE OPERATION? explaining all these.

(c) She has a 3C third degree tear. Logically outline your intra-operative interventions to ensure optimum outcome. [9 marks].

In a 3C tear both the external and internal anal sphincter are torn. The repair should only be undertaken by an experienced practitioner who is formally trained (1) trainee under supervision . To optimize the outcome repair should take place in an operation theatre because of the availability of adequate lighting, appropriate instruments and good assistants. A regional or general anesthesia (1) is preferred as it will relax the anal sphincter and help to retrieve the torn ends.

First the internal anal sphincter (IAS) should be repaired using interrupted sutures. Fine suture material like monofiolament 3 ‘0’ PDS or 2’0’ vicryl (1) can be used as it causes less migration and discomfort The external anal sphincter (EAS) can be repaired by interrupted end to end or overlapping technique without any significant difference in outcome (1) . An RCT comparing vicryl and PDS in the repair of EAS has shown no difference in the outcome measures. Burrying the knots under the superficial perineal muscles (1) help to prevent knot migration. The perineal muscles and vaginal mucosa can be repaired continuous using 2’0’ vicryl rapid. The skin should closed using subculicular suture (1) as this will reduce the short term pain compared o interrupted sutures.

A per rectal examination should be done at the end of the repair to confirm that sutures have not breeched the anal mucosa (1) . Intraoperative and postoperative broad spectrum antibiotics (1) should be prescribed as this will reduce chance of failure of repair.
Posted by PAUL A.
prt

a]Patient should be assessed quickly. From the midwife the weight of the baby and the hx of prolonged labour is asked for this spontaneous delivery before 30 minutes.Patient is asked the details about her previous obstetric history.She should be asked about previous instrumental delivery,hx of delivery of large baby more than 4kg;associated problems of prolonged previous labour or shoulder dystocia.Previous repair of 3rd or 4th degree repair done is to be elicited WHY?? JUSTIFY. What will you do differently if these risk factors were present / absent? .
She should be examined for pallor,tacycardia,hypotension to rule out PPH.Abdomen is examined to see that the uterus is well contracted post 30 minutes after delivery.She is examined digitally and by speculum if required to determine the apex of the perineal tear and to rule out cervical tear why should there be a cervical tear? Is there any association bt third degree and cervical tears? .Rectal examination (1) is done after her consent to assess the integrity of anal sphincter complex and anal mucosa.

b] Patient needs to be informed that she has tear in her anal sphincter complex while having spontaneous delivery (1) .This tear occurs in 1:100 of vaginal deliveries and its none of her fault in its occurence.She needs immediate repair for the same which is likely to be successful what does successful mean? Do 20-30% of woman have a failed repair? in 70-80% of the cases.For the repair she needs good lighting,immediate shift to O.T ?? and additional analgesia in the form of either general anasthesia of topping up of epidural if the epidural cathetar is already in place (1) .She should be explained that this surgery will have impact on her future pregnancies also. Her desire for future children should be elicited ? relevance to obtaining consent. Is this the right time to ask a woman if she wants more children?? . She should be told that she will need CS for future delivery ? evidence / rationale?? This is incorrect and women with a previous third degree tear can deliver vaginally (-1) as further vaginal delivery can undo the perineal repair.She should be told the problems of flatus/bowel incontinence,fistula formation and sexual dysfunction if the repair is not done immediately can these problems occur even after immediate repair? .Written information (1) is given for the same and proper documentation is done to take this informed consent.
To obtain consent for any operation, you need to explain: nature of operation, intended benefits, alternatives, frequent risks, serious risks, additional procedures that may be necessary, anaesthetic options and provide written info
c]Third degree3C repair should be done under all aseptic precautions in Sterile Opertion Theatre by properly trained surgeons or under proper supervision (1) and good lighting.Bladder should be cathetarised or emptied.Patient is put in lithotomy position in general/epidural anasthesia (1) .She is assessed again (1) for the extent fo the injury by careful vaginal and rectal examination.
For the optimum results of the repair various layers should be identified properly and sutured in layers.Intact anal mucosa is identified.The internal sphincter is identified and repaired using interruppted or mattress 000 PDS[polydioxanone] delayed absorbable sutures (1) .
The external sphincter complex is identified and sutured with 00 PDS using either end to end tecnique or overlapping technique (1) 000 recommended .
Rest of the vaginal mucosa and perineal body is repaired by 00 polygalactin[Vicryl] rapidly absorbable sutures.For vaginal repair continuous non locking sutures of 00 Vicryl rapid is used to prevent vaginal shortening and post partum dysparunea.Perineal skin is sutured using sub cuticular rapid Vicryl stitches (1) .Careful Vaginal and rectal examination ensures sutures not placed through mucosa is done to ascertain the completeness of repair and remove any swabs/tampoons.
Broad Spectrum antibiotics (1) should be administered at the time of repair and 1 week after.Repair should be documented properly and the clinical risk management form is filled.
Posted by PAUL A.
A.
A short history will help me to determine likelihood of a 3rd degree tear your diagnosis will not be based on probabilities and history is irrelevant as it cannot influence something which has already happened ; previous deliveries/tears, prolonged labour/2nd stage, macrosome baby, GDM/DM, shoulder dystocia. Initial assessment of blood pressure, pulse rate, blood loss & active bleeding to determine whether resucutation and immediate transfere to theatre for assessment is needed. I’ll check whether i.v. access is present and blood group-&-save was taken. See whether patient is comfortable or has epidural anesthesia, as patient in pain more difficult to assess (1) . Meticulous inspection of extent of tear to determine whether suturing in theatre is required, whether senior assistance is needed and to be able to explain patient what needs to be done. Combined vaginal-rectal examination (1) ? position of the woman? Will you obtain consent for rectal examination? is essential, as visual inspection only will often fail to identify 3rd degree tears.

B.
I’ll explain to her that the muscle around her anus (1) is likely partially damaged, something which is difficult to prevent as it is difficult to predict. Repair in suboptimal circumstances increases risk for subsequent incontinence for flatus/stools, as well as dyspareunia. Repair under optimal circumstances, with regional anesthesia for pain and good exposure/lights yields good anatomical & functional result in most cases (1) , whereas repair of poorly healed tears at later stage have a much less good outcome. I’ll explain there is a risk for infection, leading to wound breakdown (1) ; antibiotics will be given. She is likely to have perineal pain afterwards.
Consent for any operation: explain nature of operation including incisions, intended benefits, alternatives, frequent risks, serious risks, additional procedures that may be necessary, options for anaesthesia; written information. This applies to any operation and you should have followed this scheme
C.
Prior to embarking I’ll ensure good anesthesia (1) , adequate (supine) positioning she needs to be in LITHOTOMY, not supine!! and good exposure (lights) throughout. I’ll clean the perineal region and drape to create sterile field. I’ll ask the anesthetist to give stat i.v. antibiotics (cefuroxim1.5 gram + metronidazol 500 mg) (1) . I’ll first identify the internal sphincter and repair it separately with PDS 3-0 (1) . Then I’ll identify the 2 ends of external sphincter, grasp them with alice check spelling next time you are in theatre and should be capital A clamps, dissect them free if needed and suture in overlapping fashion with PDS 2-0, making sure to approximate over the entire sphincter length (1) . I’ll use continuous Vicryl 2-0 rapid for reconstruction of vaginal wall & perineum and skin subcuticular (1) . I’ll do combine vaginal-rectal examination to ascertain good reconstruction of perineal body, sphincter tone, no sutures in rectum (1) and no gauzes in vagina. I’ll finish with gauze and instrument counts (1) ? bladder catheter
Posted by PAUL A.
a - I would quickly gothrough her records to see for any potential risk factors(like big baby, malposition, premature bearing down, and use of midline episiotomy )for 3 rd degree tear,as a risk management strategy,though their predictiveness is low you are not trying to predict the tear. It has already happened and a Hx of risk factors is unhelpful .I would check her BP and pulse to confirm stable haemodynamic status.I would palpate her uterus per abdomen to confirm that it is well contracted.I would inspect her perenium under good lighting and assistants to aid proper visualisation.I would look for the apex of the vaginal wound( as it could have extended up),bleeding vessels(as prompt identification and ligating them would prevent wound hematoma which is a deterrant to wound healing),and vaginal hematomas( as they are prone to infection and ultimately compromise the surgical repair).I would do rectal examination (1) ? analgesia, consent for PR; in which position will you examine her? to see the tone and extent of external anal sphincter (EAS) damage ,and whether the internal anal sphincter(IAS) and rectal mucosa are involved so as to optimise repair.If there is any doubt regarding the structures involved i would classify it to a higher degree so to optimise surgical outcome.
b -I would explain the diagnosis to her How? . I would counsel her in a sensitive and empathetic way to allay her anxiety.I would brief her that it has longterm implications, if not repaired, such as fecal and flatus incontenence (1) and its impact on quality of life.I would tell her that she requires surgical repair under regional anaesthesia (1) in the theater for good outcome.Early repair is needed to optimise outcome.I would tell her that 60-80 % patients are asymptomatic after repair of external anal sphincter (1) .If the symptoms persist during follow up, she requires specialist referal and additional procedures too . I would provide her with written information (1) and document it. you should use the information on the consent form as the basis for your answer: explain nature of operation, intended benefits, alternatives, serious risks, frequent risks, additional procedures, options for anaesthesia, written info
d -I would give her prohylactic broad spectrum antibiotics (1) IV to minimise infectious morbidity.Bladder needs to be catheterised (1) to prevent post of urinary retention.Under regional anaesthesia (1) ? GA ,with good lighting and assistants to help and with the consultant supervision i would do the repair.I would check the sharps and swabs count before starting the repair.Bleeding vessels are secured separately to ensure adequate haemostasis. IAS is sutured with 3\'0\' PDS or 2\'0\' vicryl (1) .EAS is sutured with the same suture material in an overlap technique (1) .I would take care to bury the knots under the superficial perineal muscles (1) to prevent knot migration.I would also take care to meticulously suture all other perineal tears with what / how? .I would check the sharps and swabs count after the repair also (1) ? PR at end??. I would finally check that adequate haemostasis has been achieved before completing the repair.I would then document the whole procedure .
Posted by PAUL A.
a. Initial assessment would include elicitation of present obstetric history like whether labour was induced, duration of labour, weight of the baby, any difficulty encountered during delivery of shoulders. Expulsion of placenta will be noted. Delivery notes will be reviewed quickly to look for malpositions like persistent occipital posterior positions WHY? JUSTIFY. Will you do something different if there were no risk factors? . Thorough clinical examination for pulse, blood pressure, pallor will be done to look for hypotension due to any post partum hemorrhage which may be associated with perineal tears.Iv access will be obtained and blood to be sent for cross matching in case of bleeding. Abdominal examination will be done to find whether uterus contracted or not. Speculum examination will be done to note the extent of perineal tear and the amount of bleeding.Per rectal examination to rule out rectal mucosa injury will be performed. PR needed to diagnose 2nd or 3rd degree tear not just to look for 4th degree tear. ? analgesia, consent for PR, position during examination

b.I will explain about the perineal tear in simple terms as injury to sphincter (1) which is responsible for the continence of faeces and flatus.l will explain the need for suturing it under general/ regional anaesthesia (1) ,good lighting in operation theatre to delineate the extent of injury.The procedure will be explained as suturing the torn ends with absorbable suture material.The importance of doing the procedure for the continence of flatus and faeces will be informed (1) .Frequent risks due to the procedure are infection,dehiscence,discomfort and perineal pain.Serious risks are incontinence of flatus and faeces,fistula,sexual dysfunction (1) . .I will explain to her that post operative laxatives and antibiotics will be given to prevent infection and wound dehiscence.Perineal exercises will be taught and follow up will be done at 6-12 months by a gynaecologist with interest in ano rectal dysfunction..Consent will be obtained.Written documentation of the consultation will be done ? written information .

c.Suturing will be done by adequately trained or done under supervision (1) with good assistance.In operation theatre under adequate anaesthesia the extent of injury will be delineated (1) how? . Strict asepsis will be maintained. Intravenous antibiotics (1) particularly for anaerobic cover followed by oral antibiotics will be given for 10 days to minimize the risk of infection. The ends of internal anal sphincter identified separately and sutured with 3 0 PDS (1) .The ends of external anal sphincter are visualized and sutured by overlapping or end to end technique with 2 0 vicryl or 0 PDS you should definitely not use 0 PDS here which is associated with less discomfort and good long term spincter function compared to what? 0-PDS is definitely not associated with less discomfort .Vaginal mucosa is sutured by continuous locking non-locking recommended sutures with synthetic absorbable material PDS is synthetic absorbable!! is associated with less discomfort and dyspareunia..Perineal muscles are closed in a interrupted fashion.Vaginal skin closure done by sub cuticular sutures with vicryl which type? ,associated with less pain and wound break down. Rectal examination will be done to test the integrity how do you test this??? This is not the purpose of PR. It is to check there are no sutures through the mucosa of sphincter..Swabs and instruments count will be performed at the end of procedure (1) .Incident form will be filled and documentation of the procedure will be done carefully. .
Posted by PAUL A.
a) Initial assessment involves taking a history from the attendant midwife regarding any difficulty at delivery like shoulder dystocia which may contribute to third degree perineal tears.
Other risk factors like occipito posterior position, birth weight of baby over 4kg or a midline episotomy should be ellicited from the midwife
WHY? JUSTIFY. How will this help you decide whether she has a 3rd degree tear? .
Pain relief used in labour should be known, if had an epidural this could be topped up for perineal repair.
Amount of bleeding should be quantified as perineal tear may complicate with a post partum haemorrhage.
Her pulse and blood presure should be examined to establish she is not haemodynamically compromised.
She should be examined abdominally to make sure the uterus is well contracted.
Perineal examination how? to confirm perineal tear and exclude underlying button hole defects as these unnoticed may complicate with recto vaginal/anovaginal fistula. ensure adequate analgesia, informed consent for PR, lithotomy position and assessment by trained clinician

b)Description of the tear that involves the muscle of the anus (1) should be explained to the patient.
If any underlying risk factors for third degree tear is established this explanation should be given to her, other wise she should be told this is an unavoidable injury is a risk factor a cause? Does the absence of risk factors mean the injury was unavoidable? .
Identifying and repairing the tear will prevent long term complications like faecal/ flatus incontinence, faecal urgency in most of the cases (1) .
Explanation regarding repair in theatre will provide adequate analgesia and lighting for repair.
Regional anaesthesia/ General anaesthesia (1) is required as this will help with muscle relaxation and provide adequate pain relief with the repair.
Risk of haemorrhage and may require blood transfusion.
Risk of infection will be minimised with prophylactic antibiotics.
Risk of wound dehiscence (1) will be minimised with antibiotics and laxatives.
Explanation regarding after care of perineal wound and follow up should be explained.
A written consent should be obtained and clear documentation of all explanation in notes ? written information .

c)Perineal tear is classified as 3C Third degree tear when external and internal anal sphincter is torn.
If associated with haemodynamic compromises should encompass immediate resuscitation.
The tear should be examined and repaired by a trained obstetritian (1) trainee under supervision who has adequate training for third degree perineal repair.
Multidisciplinary approach with anaesthetics for regional/ general anaesthesia (1) for repair.
IV access for fluids and drugs administration.
Bloods should be sent for full blood count, group and save as may need blood transfusion and exclude thrombocytopenia for regional anaesthesia.
Repair should be undertaken in operating theatre for asepsis, adequate analgesia, lighting, assistants and instruments.
External anal sphincter(EAS) should be repaired either by overlap or end to end technique as both has similar outcomes.
EAS should be repaired with monofilament polydiaxaone or braided polyglactin and both have similar outcomes which size? Do you repair EAS before IAS? If not, why write it first?
Internal anal sphincter should be repaired with finer sutures like 3-0/2-0 polydiaxaone/polyglactin sutures as theases are less irritant (1) less compared to what?.
Surgical knots should be burried beneath superficial perineal muscle (1) to prevent knot migration and irritation.
Introperative antibiotics (1) should be given and continued as oral antibiotics for atleast 5 days as prophylaxis to prevent infection and wound dehiscence EUA at beginning; PR at end, bladder cath .
The operative notes should be fully documented if possible with sketches of the extent of tear and documentation of post operative plans including physiotherapy and obstetric consultant clinic follow up in 6-12 weeks.
An incident report should be made for risk management.
Posted by A S.
am
a ) Initially I will check if the woman is generally stable with normal pulse and blood pressure . I will ask about the parity , if the second stage was prolonged or precipitate . IF shoulder dystocia was encountered , what is the birth weight of the baby ? Was labour induced , was episiotomy done and if she received any form of analgesia .
Initial local assessment will include if the placenta separated or no , if not defer repair till placental separation . P/V and P/R to check presence of other injuries and extent of anal sphincteric injury .

b) I will explain to her that she has a cut in the muscles around the anus . That this is nobody s fault and it occurred during passage of the baby out of her . It should be sutured to regain continence of stools . To correct this cut she must be transferred to theatre to ensure better results . That the prognosis is generally good and after repair most women are continent(up to 80%) after one year . She will need to stay in the hospital for few more days to ensure the repair was good and her bowels are opened without marked pain or bleeding . She will need follow up and she will be taught some exercises to strengthen her pelvic floor muscles . She will need mild laxatives and analgesic tablets to ease the pain and facilitate defecation . That this may occur or not during her next delivery and decision about mode of next delivery is deferred till we see how she is doing during her follow up .

c) Intraoperative measures entails repair by well trained surgeon . Repair must be in theater . Ensure the presence of good light . Patient must receive adequate general or regional analgesia . Complete aseptic technique is essential. The patient will be in lithotomy position . Examination under anesthesia again to determine the extent of the injury . The torn internal sphincter (3C third degree) will be sutured separately by PDS or Vicryl 3/0 interrupted sutures . The external anal sphincter will be sutered by either overlapping or end to end techniques as both give the same results . The sutures will be PDS or Vicryl 3/0 and the knots will be buried inside the perineal muscles to avoid knot migration . Suturing of the vagina by continuous nonlocked vicryl rapide 2/0 then the perineal muscles and skin . Thorough heamostasis is a must . Intraoperative antibiotics including metronidazole to avoid anaerobic infection . Complete documentation of the counseling , procedure details and counting instruments and gauze is very important . Patient will be given information leaflet.
Posted by PAUL A.
I would introduce myself as a new face going to evaluate her case not necessary . I would ask if she is having other possible complications like post partum hemorrhage due to other vaginal tears. I would ask to evaluate her vital signs and to have possible resuscitation measurements including blood sample for X matching, IV cannula and fluids. I would examine her how? to exclude other possible vag tears and to determine the degree of the tear. Third degree tar can be defined as it is involving the external and internal sphincter without tearing the anal canal. However the fourth degree tear should involve the anal canal. Both should be repaired with special arrangement and informed consent obtain consent for examination including PR, position in lithotomy, good analgesia .

I would ask the patient to sign a consent form for repair before giving her any info?? . Repair should be done under regional or general anesthesia, with related consent form done by anaethetist. I would advise her to have the procedure as soon as possible without delay. I would explain the degree of the tear and the procedure of repair what is the degree of the tear and what does this mean? . I would tell her the tear involving the muscle controlling the defecation mechanism (1) and should be repaired properly to avoid stool incontinence and rectovaginal fistula (1) ; I would tell that repair will not be a contraindication to have vaginal delivery with next pregnancy. She needs a special post operative care and follow up including antibiotic, laxative, pain killer, physiotherapy and long term follow up. taking consent for any operation: explain nature of operation, intended benefits, alternatives, frequent risks, common risks, additional procedures that may be required, options for anaesthesia, written info

I would discuss the case with the consultant on call to handle the case for proper repair. I would prefer to perform the procedure in the main operating room with good lighting and assistant. I would fill the intraoperative antibiotic (1) cover including broad spectrum antibiotic (Cephalosporin) and Mertonidazole. I would ask to insert a urinary catheter (1) and to be kept for post operative period. I would examine (1) her to identify the sphincter muscle, and repair the other tears controlling the bleeding sites. Internal anal sphincter should be repaired first identifying the angle closing higher, using PDS or vicryl 2/0 edge to edge interrupted closed sutures (1) . External Sphincter should be repaired using overlapping sutures of PDS 2/0 (1) 3-0 recommended . I would continue repairing the vaginal wall, perineal muscle how & with what? , subcutaneous tissue and subcuricular vicryl 3/0 for the skin. I would do vaginal and rectal examination at the end of the procedure (1) . I would ask for instruments, gauze and swabs count (1) . I would document all findings in post operative notes and fill the incident report form.
Posted by PAUL A.
nellie

a) I would review the patient’s antenatal records and delivery notes because there will probably be risk factors for a 3rd degree tear what difference will this make? You are not trying to predict or prevent the tear - such as her being a primigravida, having persistent occipito posterior position of baby in 2nd stage. Also check BW of infant if greater than 4.5kg and was an episiotomy given- check if it was midline. Use of forceps READ THE QUESTION or a prolonged 2nd stage and shoulder dystocia will all be risk factors as well.

I will examine her after obtaining her verbal consent to check the perineum. There should be proper lighting in the delivery suite and a close inspection of the vaginal walls and a rectal (1) ? consent for PR, analgesia, position in lithotomy exam to assess the extent of the tear will be done. The anal sphincter tone will be checked and disruption of the anal sphincter muscles, both external and internal anal sphincters. Other lacerations should be excluded since it may accompany a 3rd degree, depending on the cause.

b) will you explain what a 3rd degree tear is? I would explain to her that the repair should be done to avoid anal incontinence in the future or to at least reduce the chance of this occurring (1) . I will let her know that it is best done in an operating theatre for her to have either general anaesthesia or epidural (1) if the latter was not administered in labour. This will allow the relevant tissues, that is, the sphincter muscles to be brought together without tension.

She will be told that there may still be need in the future for secondary sphincter repair if upon review she is found to have anal incontinence symptoms. The risks of the repair involves infection because of its close proximity to the rectum and fistula formation, haematoma and superficial dyspareunia (1) . If it is not repaired there is a definite risk of anal incontinence and scarring because of secondary intention wound healing (1) written info .

c) The procedure would be conducted in an operating theatre with proper lighting, assistance and instruments. She would be placed in lithotomy position and before starting the perineum/ muscles are examined (1) + PR when anaesthesia a (1) dministered to ensure extent is not greater than 3C. The anal sphincter components, external (EAS) and internal (IAS) are identified and repaired separately. The IAS is repaired with monofilament suture like 3-0 PDS in interrupted sutures (1) and the EAS with 2-0 PDS or vicryl either overlapping technique (1) or end to end anastomosis, ensuring that tension is not placed on the muscles. The knots should be buried beneath the perineal body (1) to ensure it does not migrate to the surface and cause pain. The sphincter tone is checked at this point and at every rectal examination, it must be remembered to change gloves to avoid contamination of repair with fecal matter. The vaginal mucosa can be repaired with a continuous suture using vicryl rapide and the skin closed, after the fascia closed, with a subcuticular stitch of the same suture type (1) . At the end, there must be a check of instruments, needles and swabs to ensure all are accounted for (1) PR to ensure no suture in mucosa, bladder cath .
Posted by Priti T.
Dera Dr Paul,
I would like to know why u have underlined whole of my answer?I understand that u underline those lines which should be written differently or u think are incorrect.Yet u have awarded marks.If all was incorrect then no mark should have been given.I value yr opinion as I think despite knowing the subject exactly what may or may not be written makes a difference for SAQs and thats what u want to teach us.Thanks.waiting for yr reply
Dr priti

sorry there was a bug in the code used to underline and the stop code was written incorrectly. this has been fixed
Posted by PAUL A.
a)Her delivery notes should be reviewed for risk factors for 3rd degree perneal trauma include precipitated labour, induced labour and big baby JUSTIFY – why? How will the presence / absence of risk factors determine whether or not the tear is a 3rd degree? . Perineal tear is associated significant physical and phypsychological impact, thus the extent of perineal injury should be assessed properly how? . Involvement of cervical tear should be rule out why? Is there any association between cervical and third degree tears?? . The amount of bleeding should be noted. Blood pressure should be measured, if there is presence of hypotension resuscitation should be initiated. Full blood count and group and save should be send and intravenous access should be secured.
b) She should be explained that third degree tear is the injury involving anal sphincter (1) . She should be ensured that success rate of repair is 60-80% after 12 months what does ‘success’ mean? Do 20-40% of women have an open wound? . She should know that she should be examined under anesthesia to establish the extent of her perineal tear. The risk of wound breakdown and knot migration should be explained. Long term complication like bowel or flatus incontinence should be informed to the patient (1) Take a look at a consent form – what do you have to go through before the woman signs the form? Nature of procedure, intended benefits, alternatives, frequent risks, common risks, additional procedures, anaesthetic options, written information.
c. The surgery should be done by well trained surgeon or under appropriate supervision (1) . It should be done in operation theatre under anesthesia (1) to ensure good lighting and good exposure. The procedure should be done with proper sterilization. Identification of correct anatomy is important before starting any repair EUA to ascertain extent of injury . The internal and external anal sphincters are repaired with 3O PDS (1) are these repaired separately?? . The knots should be buried bellow the superficial perineal muscle (1) to reduce risk of knot migration. The perineal body should be reconstructed to support the repaired anal sphincter. Vaginal and rectal examination should be done to check the integrity of the suture. Broad spectrum should be given to prevent infection (1) will you repair the vagina / perineal muscle / skin? PR to ensure sutures not placed through mucosa; bladder cath .
Posted by PAUL A.
AH
a)I will quickly peruse the antenatal record and more importantly the labour and delivery record. I will look for risk factors for anal sphincter injury WHY? If there were no risk factors, will you walk away? . These include forceps delivery READ THE QUESTION – spontaneous vaginal delivery , innduction of labour, persistent occipito-posterior position,prolonged second stage, shoulder dystocia and nulliparity.
I will check the blood loss and previous haemoglobin to determine need for fluids or blood transfusion. This will be relevant if general anaesthesia is required.
A quick why does it have to be quick? If it is needed, it must be thorough general examination followed by a meticulous examination of the perineum via per vaginal and per rectal examination will be done (1) .
I will check if an epidural is in situ and if it requires top up are you going to do this AFTER you have examined her? . The anaesthetist will be asked to review the patient and discuss with her the type of anaesthesia to be used.
If she had postpartum haemorrhage, blood will be sent for a check haemoglobin.
b)I will explain to her the nature of the injury what is the nature of the injury? and that it needs to be repaired in theatre by a senior officer who is trained to recognise and correct the defect.She will be examined prior to the repair by the person doing it. It will be done under regional or general anaesthesia (1) .
She will be told that the possible complications are perineal pain, dyspareunia, and knot migration to the perineum. Fecal incontinence and flatus incontinence can occur even after proper repair and repeat surgery may be required (1) .
She would be advised that she would need analgesia and antibiotics and they would be safe to use if she is breastfeeding.
She will be given information leaflets (1) and proper documentation will be done in her notes

c)The repair will be done in theatre where good lighting. proper instruments, and aseptic conditions are available. The patient will be placed in lithotomy position and an assistant will be required.
The repair will be done under general or regional anaesthesia (1) so that the sphincter muscles will be relaxed for proper apposition without tension ? EUA .
A fine suture will be used, either 3-0 polydioxanone (PDS) or 2-0 polyglactin.(Vicryl). The internal anal sphincter will be repaired separately with interrupted sutures using PDS (1) . The external anal sphincter wiill be erepaired using an end to end or overlapping procedure as the results are equivalent with either (1) .
Broad spectrum intravenous antibiotics (1) will be commenced intraoperatively and continued orally postoperatively.
A rectal examination will be done after repair to ensure its integrity no sutures placed through mucosa and all swabs, instruments and needles will be counted and accounted for (1) bladder cath .
Proper recording will be done.
Posted by PAUL A.
(a) I would like to know some details about the delivery like prolonged second stage, weight of the baby, occipito-posterior position, midline episiotomy and any previous 3rd or 4th degree tear, as all these factors are related to increased chance of extensive perineal trauma You are not trying to predict the event – it has already happened and the presence / absence of these factors will not alter anything . I would like to assess patient\'s general condition(pulse, bp and amount of blood loss if having bleeding) to assess the need for resuscitation and to accelerate the process of repair. I will take consent (1) ensure adequate analgesia and will do the examination under good light and analgesia.(entonox) I will do the vaginal examination and rectal examination (1) to confirm the type of perineal tear for proper management and counselling of the patient.

(b) I would tell her that she has a tear down below near her back passage is this a third degree tear? and it needs repair under anesthesia in good light and aseptic condition to have a good outcome. I will tell her the risk of infection, haemorrhage and incontinence of faeces and flatus incase of non-repairing of tear (1) can these occur even after repair? . She may need blood transfusion incase of heavy bleeding during repair. She will need long term follow up to be assured that there is no residual problem. I will explain to her the procedure and take informed consent for blood transfusion and repair of perineal tear. take a look at a consent form. What do you have to go through before the woman signs the form? Explain nature of the procedure, intended bebefits, alternatives, frequent risks, serious risks, additional procedures, options for anaesthesia, written information

(c) 3C tear is a perineal tear which involves the whole of internal as well as external anal sphincter. It should be repaired by an experienced surgeon or by a trainee under supervision (1) to have good outcome. It should be performed in the theater in good light and with good assisstance under anesthesia (1) which can be a regional block. I will reexamine her under anesthesia (1) to confirm my findings and extent of injury. Internal Anal sphincter should be repaired with 3/0 pds (1) because it has a high tensile strength and will take a long time to get absorbed. I can use end to end technique or overlapping technique as both of these techniques have the same results. External anal sphincter will also be repaired by the same technique by 3/0 pds (1) . I will suture the vaginal mucosa with 2/0 vicryl rapide by continous sutures and also the perineal muscle will be sutured in the same way. Skin should be approximated by subcuticular vicryl after proper hemostasis has been secured as it will reduce the post operative pain. On completion of the surgery I will do a vaginal and rectal examination what will you be looking for? and per rectum suppositries for analgesia not to be given. Intraoperative antibiotics (1) (broad spectrum + metronidazole for anaerobes) should be given. I will make sure that my swabs, needles and instruments are correct (1) and blood loss should be estimated. I will properly write the operative notes describing findings and all the steps of surgery.
Posted by PAUL A.
A:
Initial assessment involves hemodynamic stability of patient (B.P, pulse), amount of bleeding should be quantified as perineal tear may complicate with a post partum haemorrhage.
Assess patients level anxiety. A quick history from the attendant midwife regarding any risk factors i.e. difficulty at delivery like shoulder dystocia which may contribute to third degree perineal tears.Other risk factors like occipito posterior position,macrosomia or a midline episotomy should be ellicited from the midwife why does the Hx have to be quick? How will it help you? You are not trying to predict the tear and the presence / absence of risk factors will not alter what has already happened .Any comorbidities for anesthesia should be noted.Anagesia used in labour , if had an epidural this could be topped up for perineal repair what about for the examination? .
She should be examined abdominally to make sure the uterus is well contracted. Detailed systematic perineal, and vaginal examination to assess severity of damage. Rectal examination to exclude any button hole tears as these may complicate with recto vaginal/anovaginal fistula PR is essential to diagnose 2nd / 3rd degree tears not just to exclude a button-hole injury .

B: Explain the extent of damage and anatomical structures involved how does the examiner know that you know the structures involved? Mehod of repair intended which is what? . And explain the need for repair in operation theatre under anagesia (regional or general) (1) as immediate repair under adequate anesthesia is associated with improved outcome.Need of post operative antibiotics and risk of post op wound infection, dehiscence persistent anal symptoms (1) , need for long term follow up will be explained.
take a look at a consent form and see what you have to go through before the woman signs the form
C:
A good repair of sphincter is imperative as this is the factor most strongly associated with future continence
Repair under adequate anesthesia (1) in theatre, with proper assisstance and supervision (1) . Detailed examination (1) before repair. .Accurate identification of extent of damge and structures involved, secure hemostasis.Use of delayed absorbable suture (2/0, 3/0 PDS), is associated with better long term outcome and less wound infection. Use broad spectrum antibiotics (1) intraoperatively.All instruments swabs and needles should be accounted for (1) this is a very superficial answer. Will you repair IAS, EAS, perineal muscles, vaginal wall, skin; PR at end, bladder cath? .
Posted by Hassan A.
a- i will check her vital signs & her general condition & assure iv access
-explain the reason for my examination to the patient & obtain her consent
-with adequate analgesia & light i will perform systematic examination , assessing uterine tone,presence or absence of bleeding, perform p/v to assess the extent of tear & rule out presence of other tears or lacerations, rectal examination to assess integrity of rectal mucosa & presence of tone & degree of involvement of external anal sphincter & check for internal anal sphincter involvement.
b-i will explain to her that third degree tear is a major complication that occurs in 1% of vaginal deliveries & if left untreated she would suffer fecal incontinence , so there is no place of no intervention in this condition.
in order to perform repair it would be in operation theater & she will need regional analgesia or anaesthesia.
the prognosis after surgical correction is good (60-80%) asymptomatic at 12 months, & those who are symptomatic usually complain of incontinence to flatus or fecal urgency.
post operative complications include pain, infection, dehisence of suture line, formation of rectovaginal fistula or presence of incontinence which may need further surgical intervention.
she will need post operative laxatives & she will need physiotherapy 6-12 weeks postoperatively.
regarding her future deliveries , she will be prone for recurrence or worsening of symptoms & she can choose elective cs.
c-under regional analgesia or general anesthesia with adequate light, reassessment of the extent of sphincter injury with clear documentation.the surgeon should be adequately trained for treatment of such injury or supervised by an experienced surgeon
-broad spectrum IV antibiotic should be administered.
3C third degree perineal tear involves full thickness of external anal sphincter & internal anal sphincter
internal anal sphincter should be identified & repaired with interrupted fine suture (3-0 PDS ), external anal sphincter should also be repaired by interrupted sutures either end-to end or by overlap techniques & care should be taken to bury the knots under the superficial perineal muscles to avoid irritation. then suturing the rest of episiotomy layers.
vaginal & rectal examination to check for integrity of suture line.
check for hemostasis & complete swab counts.
Posted by PAUL A.
KP

a) The initial assessment would aim to find the risk factors associated with third degree tear like nulliparity , epidural anaesthesia, prolonged 2nd stage ,persitent occipitoposterior position of fetus. Delivery of big baby, manoeuvres of shoulder dystocia also increases the probability of tear. Midline episiotomy can get extended to the anal sphincter the tear has already happened and the absence of risk factors will not change it. Therefore risk factors are irrelevant . Enquiry about medical disorders READ THE QUESTION – HEALTHY WOMAN to check for the fitness to surgery. General examination includes pulse and blood pressure for the hemodynamic status. Abdominal palpation to check whether uterus well contracted. Local examination where is local?? to rule out nature and extend of tear , any other tears and whether patient is actively bleeding in which case repair should be expedited. Veinflon to be sited and bloods to send for FBC and group and save.


b)I would tell her the nature and the severity of the injury. The tear has involved the sphincter muscle (1) that plays a role in anal continence. The importance to suture in theatre for proper assessment and also as there is availability of adequate lights, proper instruments and assistant. The need to suture under anesthesia (1) preferably regional so that the muscle can be properly approximated as they are relaxed. The prognosis is good if sutured in theatre and under anesthesia. I would inform her the complications of anesthesia like nausea , vomiting and headache and surgical complications like infection , pain , bleeding , incontinence of flatus and faecal (1) . Foleys Catheter for 12 hours as she may have retention of urine due to pain and anaesthesia. Intravenous antibiotic in theatre to optimise the risk of infection.

c)The repair should be done in theatre with regional anaesthesia and patient in lithotomy position (1) . A through assessment how?? of the severity of tear should be done prior to suturing. Also check for any other tear involving vaginal walls or parauretral .
In 3c tear there is involvement of both external and internal anal sphincter.
The external anal sphincter (EAS) should be sutured with overlapping or end to end technique as both has equivalent outcome. The suture material use would be either monofilament polydioxane or modern braided polygalactin (1) ? size . The internal anal sphincter should be suture with interrupted technique and fine suture should be used as PDS 3-0 or vicryl 2-0 for less discomfort and irritation do you suture EAS before ISA? If not, why did you write suturing of EAS BEFORE IAS?? . The knot should be buried beneath the muscle which muscle? The sphincter muscle?? to prevent knot migration to the perinal skin which can be very uncomfortable and painful. Perrectal exnamination to ensure suture not gone through rectum (1) as can lead to fistula formation. Foleys catheter to be inserted (1) . Swabs, instruments and needle should be checked (1) . Proper documentation of nature of injury, technique and suture material used.. Postoperative plan for antibiotics will you give intra-op antibiotics?? and laxatives to decrease incidence of wound dehiscence. Incident form should be filled.